ML20216F231
| ML20216F231 | |
| Person / Time | |
|---|---|
| Site: | Peach Bottom  |
| Issue date: | 06/22/1987 |
| From: | Zech L NRC COMMISSION (OCM) |
| To: | Glenn J SENATE, GOVERNMENTAL AFFAIRS |
| Shared Package | |
| ML19306F098 | List: |
| References | |
| NUDOCS 8706300829 | |
| Download: ML20216F231 (8) | |
See also: IR 05000278/1985022
Text
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Distribution:
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UNITED STATES
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NUCLEAR REGULATORY COMMISSION
WRussell
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WASHINGTON, D. C. 20555
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June 22, 1987
.Scollins
RGallo
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CHAIRMAN
EDO 2867
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The Honorable John Glenn, Chairman
LPDR
Committee on Governmental Affairs
Cormonwealth of
United States Senate
20510
Docket # 50-277/278
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Dear Mr. Chairman:
I am responding to your letter of May 13, 1987.
The reply to the
request from Senator Heinz for information regarding specific
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steps taken to date during our ongoing investigation of the Peach
Bottom matter is enclosed.
The staff had been monitoring the performance at Peach Bottom for
some time prior to the March 1987 shutdown due to the utility's
There had been a number of escalated
performance history.
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enforcement actions and, as a result of the declining trend
evidenced in the 1986 SALP, a diagnostic team inspection was
performed in June 1986.
That inspection concluded that
substantial overall improvements in performance were necessary.
In light of our previous concerns and the seriousness of the
March, 1987 allegation concerning Peach Bottom operators, our
action was necessarily immediate.
Senator Heinz refers to an incident in the control room at
Peach Bottom in June 1985.
During a Region I inspection at the
10, 1985, one of our inspectors
Peach Bottom facility on June
identified an individual who appeared to be inattentive to his
As a result of this observation, a special inspection was
duties.
conducted and subseqently NRC Region I staff held an enforcement
I
conference with the utility.
There were no allegations regarding control room conduct
associated with the June 1985 event, however, and NRC has received
no allegations associated with operator attentiveness other than
I am enclosing
the recent allegation which led to the shutdown.
I inspectinn report, report of the enforcement
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the Region
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for
conference and the utility's response to the June 1985 event,
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I am also enclosing the recent order suspending
your information.
power operation, the utility's response and a copy of a special
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inspection report dated May 12, 1987.
Originated:
RI:Cowgill
8706300829 G70622 ,
hDR
ADocg 9599997
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Thank you for.-your interest in this matter, and I trust iihat the
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information provided is responsive to your and Senator Heinz's
requests.
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Sincerely,
b t~.LandoW.Zch,[4.
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Enclosures:
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As Stated
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cc:
Senator William Roth
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Senator John Heinz
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QUESTION 1
With regard to the colit shutdown of the Peach Bottom Nuclear
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Power Plant, please describe from the beginning the specific
steps involved in the NRC's inquiry, together with the date of
each step and the cause for taking such a step.
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ANSWER.
During 1985 and 1986 the NRC staff m nitored Peach Bottom closely due to the
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utility's performance. There had beti, a number of escalated enforcement
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actions and, as a result of the dociidng trend evidenced in the 1986 SALP, a
diagnostic team inspection was perfe n.2d in June 1986. That inspectitr.
concluded that substantial overall w.provements in performance were
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The chronology of sters be. ginning with an anonymous phone call and
necessary.
leading to the cold shutdown of tre Peach Bottom Nuclear Power Plant follows.
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CHRONOLOGY
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March 24, 1987 -
8:05 A.M.
Call to Region I from
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Headquarters Duty Officer
stating that he had received
anonymous call about sleeping
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at a power plant. The calier
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would not identify plant.
approximately 9:30 A.M.
Call from alleger. After
lengthy discussion, determined
plant was Peach Bottom.
1:30 P.M.
Meeting in Regional
Administrator's office
concluded that 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> per
day site coverage would be
4
initiated while investigating
allegation.
3:00 P.M.
Began 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> per day site
,
coverage with random frequent
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visits to the control room.
March 25, 1987
Morning
NRC investigator and
inspector interviewed alleger.
A11eger was determined to be
credible.
Afternoon
Began " essentially full time"
coverage of control room
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activities.
March 26, 1987
8:30 A.M.
Interviewed alleger,
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2:20 P.M.
Meeting in Regional
Administrator's office, at
which it was decided to
interview additional
individuals beginning
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March 27 at the site to
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verify alleger's assertions,
8:00 P.M.
NRC management called PECO
to obtain space at Peach
Bottom beginning March 27
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to conduct interviews.
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March 27, 1987 -
Morning
NRC investigators on site
conducting interviews. NRC
management on site.
March 20, 1987
Morning
NRC management toured site.
NRC investigators onsite
conducting. interviews.
March 29, 1987
NRC management toured site.
NRC investigators on site
conducting interviews.
March 30, 1987
10:00 A.M.
Meeting in Regional
Administrator's Offico
regarding results
of investigation to date.
Decision made to issue order.
Reasons for order are
contained in the order.
March 31, 1987
11:00 A.M.
Regional Administrator and
Staff met with PECO to issue
order.
11:40 A.M.
Unit 3 began shutdown.
Unit 2 already in cold shutdown
NRC management on site to
assist inspector.
11:35 P.M.
Unit 3 in cold shutdown.
PECO executives meet with
April 2,1987
Regional Administrator
I.
regarding initial actions in
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response to Peach Bottom
order.
Terminated 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> coverage
April 3,1987
5:00 P.M.
Call from (PECO) regarding
initial actions in response
to Peach Bottom order.
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April 6, 1987
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PECO holds press conference
to describe initial actions.
Issues letter to NRC respon-
ding to Order as required.
April 9,1987
Exit meeting at Peach Bottom
plant for Special Inspection
87-10
April 10, 1987
Regional Administrator and
staff brief ACRS and
Commission.
April 14, 1987
NRC staff meet with State of
Maryland regarding Peach
Bottom..
May 5, 1987
PECO senior management meets
with Deputy Executive Director
for Operations & Regional
Administrator in Region I
.
office on status of PECO's
investigation.
NRC staff meets with
May 6, 1987
Commonwealth of Pennsylvania
regarding status of Peach
Bottom.
May 12, 1987
Special Inspection Report
87-10 issued.
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NRC staff meets with PECO at
May 15, 1987
site to discuss status of
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Peach Bottom with regard to
pending fuel load activities
for Unit 2.
Conference call with PECO
May 19, 1987
regarding status and plan
for fuel load of Unit 2.
April - May, 1987
Ongoing NRC interviews
with contractor & PECO
management
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QUESTION 2.
Were any allegations of problems received in addition to the
June 1985, allegation of control room problems? If so, what was
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thesubstanceofsuchallegation(s)andwhenweretheyreceived
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by the NRC?
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ANSWER.
During a Region I inspection at the Peach Bottom facility on June 10, 1985,
one of our inspectors identified an individual who appeared to be inattentive
to his duties. As a result of this observation, a special inspection was
conducted and subsequently NRC Region I staff held an enforcement conference
with the utility. There were no allegations regarding control room conduct
associated with the June 1985 event, however, and NRC has received no
allegations associated with operator attentiveness other than the recent
allegation which led to the shutdown order.
1
(Question 2 and 3 are answered under the assumption that they are directed
toward allegations of control room problems. Twenty-six allegations are
recorded as having been received on other matters since 1982. They can be
{
made available should the Consnittee desire to broaden the question).
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._urther describe what action * iany allegation, including tha
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QUESTION 3.
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ANSWER.
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As stated above, there were no allegations regarding control room conduct
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associated with the June 1985 event. The attached inspection report, report
of the enforcement conference and the utility's response describe the NRC's
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and Philadelphia Electric Company's actions in this matter.
(Question 2 and 3 are answered under the assumption that they are directed
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toward allegations of control room problems. Twenty-six allegations are
recorded as having been received on other matters since 1982. They can be
made available should the Comittee desire to broaden the question).
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JUN 18 1985
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Docket No.
50-278
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License No. OPR-56
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Philadelphia Electric Company
ATTN: Mr. S. L. Daltroff
.
Vice President
Electric Production
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2301 Market Street
Philadelphia, Pennsylvania
19101
Gentlemen:
Subject:
Inspection 50-278/85-22
This transmits the findings of a'special safety inspection conducted by a
Regional Inspector and the Senior Resident Inspector on June 10 - 13, 1985 at the
Peach Bottom Atomic Power Station, Delta, Pennsylvania. The inspection con-
sisted of a review of the events surrounding an apparent inattentive Unit 3
licensed reactor operator as observed by an NRC Regional Inspector at approxi-
mately 6:15 a.m. on June 10, 1985.
,
These findings were based on observation of activities, interviews, document
'
reviews, and were discussed at an inspection exit meeting conducted with Mr. R.
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S. Fleischmann and other members of your staff on June 13, 1985. Areas examined
during this inspection a're described in;the NRC Region I Inspection Report
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which is enclosed with this letter.
Based on the results of our inspection, we are concerned about the apparent
inattentiveness of the on-shift Unit 3 licensed reactor operator and in
addition, the NRC is concerned regarding the operator's apparent enticing of
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the NRC Region.l Inspector as documented in the plant staff investigation
a
of this occurrence. An enforcement conference has been scheduled for 10:00
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a.m. Friday, June 21, 1985, in the NRC Region I office to further discuss these
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At this conference, you should be prepared to discuss the concerns
concerns.
identified in the enclosed inspection report and corrective actions taken or
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planned. In addition, the licensed operator involved in this situation is
requested to attend this conference.
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The need for and nature of appropriate enforcement action relative to the
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issues identified in the enclosed report will be considered after this con-
ference and will be the subject of separate correspondence at a later time.
No
response to this letter is required.
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0FFICIAL RECORD COPY
IR PB3 85-22 - 0001.0.0
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06/17/85
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JUN 18 1985
Philadelphia Electric Company
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Your cooperation with us is appreciated.
Sincerely,
._
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Richard W. Starostecki, Director
Division ,of Reactor Projects
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Enclosure:
NRC: Region I Inspection Report No. 50-278/85-22
cc w/ enc 1:
r R. S. Fleischmann, Manager, Peach Bottom Atomic Power Station
vJohn S. Kemper, Vice President, Engineering and Research
-Troy B. Conner, Jr. , Esquire (Without Report)
- Eugene J. Bradley, Esquire, Assistant General Counsel (Without Report)
- Raymond L. Hovis, Esquire (Without Report)
Thomas Magette, Power Plant Siting, Nuclear Evaluations (Without Report)
- A. J. Pietrofitta, General Manager, Power Production Engineering,
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Atlantic Electric
Public Document Room (PDR)
Local Public Document Room (LPOR)
Nuclear Safety Information Center (NSIC)
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M RC Resident Inspector
Commonwealth of Pennsylvania
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bec w/encis:
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- Region I Docket Room (with concurrences)
Senior Operations Officer (w/o encis)
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- R. Gallo, Section Chief, ORP
- S. Collins, Chief PB No. 2
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- H. Kister, Chief PB No. 1
W. Russell, A/D, ONFS, NRR
-0. Holody, ES, RI
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ORP. I
rostecki
RStg/85 ,
Johnson
Florek
Bettenhausen
3a o
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6/b
6//7/85
6//)/85
6//7/85
54/85
6/$/85
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0FFICIAL RECORD COPY
IR P83 85-22 - 0002.0.0
06/17/85
9 01
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U. S. NUCLEAR REGULATORY COMMISSION
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REGION I
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Report No. 50-278/85-22
Docket No. 50-278
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License No. OPR-56
Licensee:
Philadelphia Electric Company
e
2301 Market Street
Philadelphia, Pennsylvania
19101
Facility Name:
Peach Bottom Atomic Power Station Unit 3
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Inspection at:
Delta, Pennsylvania
Inspection conducted: June 10 - 13, 1985
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Inspectors:
T. P. Johnson, Sr. Resident Inspector
0. J. Florek, Lead Reactor Engineer
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Reviewed by:
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J. E. Beal), Project Engineer
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Approved by:
dat'e
Robert M. 3 allo, Chief
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DRP, Section 2A
June 13,1985 (Inspection Report 278/85-22) special
Inspection Summary:
1.ispection regarding routine safety and followup of events surrounding an
NRC regional inspector's observance of an apparent inattentive Unit 3
This inspection involved 10 hours1.157407e-4 days <br />0.00278 hours <br />1.653439e-5 weeks <br />3.805e-6 months <br /> by
on-shi f t licensed reactor operator.
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one resident inspector and one regional inspector.
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Concerns were identified regarding:
(1) ths apparent inattentiveness
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Results:
to licensed duties by the on-shift Unit 3 licensed reactor operator, and (2)
the operator's apparent enticement of an NRC regional inspector as concluded '
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by the licensee's investigation.
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DETAILS
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1.
Persons Contacted
1.1
Licinseepersonnel
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"R. S. Fleischmann, Manager, Peach Bottom Atomic Power Station
- D. C. Smith, Superintendent Operations
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- Present at exit interview on site and for summation of preliminary findings.
1.2 NRC Inspection Participants
T. P. Johnson, Senior Resident Inspector
D. J. Florek, Lead Reactor Engineer
2.
Purpose, Background and Sequence of Events
2.1 Purpose
In order to support inspection of the Peacn Bottom Unit 2 outage
recovery activities the regional inspector had been on-site since
June 9, 1985, observing the Unit 2 containment integrated leak rate
test (ILRT).
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On June 10, 1985, at approximately 6:15 a.m. an NRC regional inspector.
was present in the control room, while inspecting the Unit 2 contain-
At that time, the inspector observed the Unit 3 on-shift
ment ILRT.
licensed reactor operator with his eyes closed and head tilted back
while sitting in a chair adjacent to the reactor control paaal.
The purpose of this special inspection is to review the events
surrounding an NRC regional inspector's observance of apparent
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inattentiveness to licensed duties by the Unit 3 on-shift licensed
a
reactor operator,
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2.2 Background
Peach Bottom Units 2 and 3 share a common control room (see Attach-
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ment 1). The following licensed personnel are normally assigned
on-shift duties in the control-room: Unit 2 reactor operator, Unit 3
The Unit 2
reactor operator, control operator and shift supervisor.
reactor operator has responsibilities for the south en* of the
control room (Unit 2 control boards); the Unit 3 reactor operator
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has responsibilities for the north end of the control room (Unit 3
control boards) and the control operator has responsibilities for
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the central (common) control boards. The shift supervisor has a
desk in the control room on the north (Unit 3) side.
Inaddition,
each shift has a senior licensed shift superintendent who has an
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of fice in the control room; however, this office is outside the area
of the control room panels.
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At the time of the occurrence, Unit 3 was operating at 78% power
Unit 2 was in cold
in extended core flow at the end of cycle six.
shutdown with the containment ILRT in progress.
No testing nor
abnormal plant operations were in progress at Unit 3.
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2.3 Seouence of Events
Date
Time
Event
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6/9/83
5:00 a.m.
NRC regional inspector on-site to '
observe Unit 2 containment ILRT
(Sunday).
6/10/85
5:00 a.m.
NRC regional inspector again on-site
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to observe Unit 2 containment ILRT
(Monday).
6/10/85
5:06 a.m.
NRC regional inspector enters
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control room and exits one minute
.
later.
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6/10/85
6:05 a.m.
NRC regional inspector re-enters
control room to discuss ILRT with
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test director.
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NRC regional inspector observes on-
6/10/85
Approx.
6:15 a.m.
shift Unit 3 licensed reactor
operator with eyes closed, and head
"
tilted back on his chair.
Inspector
informed Shift Supervisor, who talks to
operator.- Inspector exits control
room.
6/10/85
6:26 a.m.
NRC regional inspector again
re enters control room and observes
.
that Unit 3 reactor operator is
attentive to duties.
Inspector
exits control room a few minutes
later.
6/10/85
7:00 a.m.
Unit 3 reactor operator relieved due
to shift change.
NRC regional
inspector informs NRC resident
inspectors of observations regarding
the Unit 3 reactor operator.
6/10/85
8:00 a m.
NRC regional inspector informs
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Superintendent Operations of
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situation.
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6/10/85
8:15 a.m.
Region I management notified of
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situation.
6/10/85
Approx.
NRC regional and residt.nt inspectors
Noon
discuss situation with the
Superintendent Operations.
6/10/85-
11:00 p.m. -
Licensee conducts interviews with
6/11/85
7:00 a.m.
control room participants and
performs investigation
6/11/85
8:00 a.m.
NRC regional inspector discusses
situation with Manager, PBAPS and
Superintendent Operations
6/11/85
Approx.
Licensee takes disciplinary action
9:00 a.m.
against Unit 3 licensed reactor
operator.
6/11/85
Approx.
NRC resident inspector discusses
Noon
situation and disciplinary action
taken with Manager, PBAPS and
Superintendent Operations.
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6/12/85
9:00 a.m.
NRC resident inspector reviews
written statements from operators
involved and written investigation
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by the licensee.
Further discusses
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event with Manager, PBAP5.
6/12/85
5:00 p.m.
After concluding the PBAPS SALP
meeting, NRC RI management are
briefed on situation by licensee
management.
3.
Discussion
(Refer to the enclosed figure, Attachment 1, for ' control room locations as
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At 6:05 a.m. on June 10, 1985, the NRC
1
noted by numbers in parentheses.)
regional inspector entered the control room (1) from the Unit 2 side vital
door. The NRC regional inspector discussed ILRT items with the ILRT test
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director and was preparing to leave the control room with the test director
when the regional inspector observed the on-shift Unit 3 reactor operator
sitting in a chair (3) at the Unit 3 reactor control panel in a question-
The inspector crossed the control room to the
able physical position.
Unit 3 side (4) to obtain a better observation of the Unit 3 reactor
operator's physical pusition. The inspector noted that the operator had
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his eyes closed. and his head tilted back on his chair.
The inspectbr 'then
moved to the shif t supervisors dest (5) and told him that there appeared
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to be a problem with the Unit 3 licensed reactor operator.
The shift
supervtsor walked over to observe the Unit 3 reactor: operator (6) and the-
inspector remained at the shift supervisor's desk (5D The.shif t super-
visor thertspoke the' operator's name.in an apparently normal tone of
vnice. The regional inspector's initial recollection of the event observed
what appeared to be the shift superv5sor reaching out to the. operator and
the inspector assumed physical contact was made. However, in subsequent
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recollections, the inspector cou u not. be sure that physical contact was
in fact made.
Following the interaction with the shift supervisor, the
operator quickly restored his head to an erect position, with eyes opened
and appeared to be aware of his surroundings.
The shift supervisor
returned to h-is normal. station (5) and informed the inspector he would
" keep an eye on the operator". The inspector then left the control room
(1) with the ILRT test director.
Approximately 10 minutes later the inspector revisited the control room
and no further problems were.noted. The inspector discussed the Unit 3
reactor operator's status with the shift supervisor (7) and the shift
supervisor indicated that the operator was, capable of maintaining his
station. The shift supervisor also indicated that he did not believe the
operator was " sleeping" at the time.
The regional inspector infornied the resident inspectors of the events at
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about 7:00 a.m. on June 10, 1985, and informed the Superintendent Operations
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at approximately 8:00 a.m. while in the bridge connecting the administra-
tion buildingste the power block. AT 6:15 a.m. the resident-taspector
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notified P.egion I management of this situation.
The resident inspector
and tha' regional inspector had further discussions with the Superintendent
Operations at approximately noon the same day.
11, 1985, at approximately 8:00 a.m. adattional discussions were
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On June
held between the regional inspector and the Manager, PBAPS and Superin-
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tendent Operations regarding the assumed physical contact between the
shift supervisor and operator. During these discussions, the regicnal
inspector indicated that he could not be sure that physical contact was
indeed made when the shift supervisor initially spoke to the operator.
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The licensee conducted an investigation of the event on June 10 - 11,
1985, during "Z" shif t (11 p.m. to 7 a.m.).
The investigation was performed
by the Operations Engineer and reviewed by the Manager, PBApS and Superin-
tendent Operations. Disciplinary action was then by the Manager, PBAPS
regarding the performance of the Unit 3 reactor operator at 9 00 a.m. on
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June 11,1985. - The resident inspector subsequently reviewed the licensee's
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investigation findings including the following items:
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Statement of on-shift Unit 3 licensed reactor operator
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Statement of the on-shift Shift Supervisor
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Statement of the en-shift Shift Superintendent
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Investigation report by the Operations Engineer
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In summary, the licensee's. investigation concluded the following:
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The'on shift Unit 3 reactor operator's eyes were'glosed, however he
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was not asleep.
The NRC regional inspector observed the Unit 3 reactor operator
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with his eyes closed.
The Unit 3 reactor operator was enticing the NRC regional inspector
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to believe he was asleep.
The resident inspector discussed the results of the licensee's investiga-
tion and the disciplinary actions taken regarding the performance of the
Unit 3 reactor operator with the Manager, PBAPS at approximately 9:00 a.m.
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on June 12, 1985.
4. Conclusion -
The on-shift Unit 3 licensed reactor operator, the operator "at the
controls," was apparently inattentive in that his eyes were closed and
his head was tilted back on his chair while at the Unit 3 reactor control
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panel.
In addition, the licensee's evaluation concluded that the reactor
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operator was apparently enticing the NRC regional inspector to
believe that he was asleep.
(UNR 278/85-22-01)
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=5.
Management Meetings
5.1 On June 12, 1985, following the previously scheduled Peach Bottom
SALP meeting, NRC Region I management were briefed by licensee
management regarding this situation.
Individuals attending this
briefing are included in Attachment 2.
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On June 13, 1985, a verbal summary of preliminary inspection findings
5.2
was provided to the Manager, PBAPS and to the Superintendent Operations
at the conclusion.of the special inspection.
No draft inspection
report material was provioed to the liensee during the inspection.
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ATTACHMENT 2
NRC:RI and Licensee Management Meeting on June 12, 1985
Name
Title
-
T. P. Johnson
NRCiRI Senior Resident Inspector
-
D. J. Florek
NRC:RI Lead Reactor Engineer
R. M. Gallo
NRC:RI Chief, Reactor Projects Section 2A
S. J. Collins
NRC:RI Chief, Reactor Projects Branch 2
T. E. H0rley
NRC:RI Regional Administrator
R. W. Starostecki
NRC:RI Director, Division of Reactor Projects
R. S. Fleischmann
PEco Manager, PBAPS
W. T. Ullrich
PECo Superintendent, Nuclear Generation Division
M. J. Cooney
PEco Manager, Nuclear Production
S. L. Daltroff
PEco Vice President, Electrical Production
PEco Senior Vice President, Nuclear Power
V. S. Boyer
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JUL 1 7 2 5
Docket No. 50-278
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License No. DPR-56
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EA 85-75
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Philadelphia Eiectric Company
.
ATTN: Mr. S. L. Daltroff
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-
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Vice President
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Electric Production
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2301 Market Street
Philadelphia, Pennsylvania 19101
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Gentlemen:
1
'
Subject: Enforcement Conference
(Inspection 50-278/85-22)
an enforcement conference was conducted with you, members of
On June 21, 1985,
your staff, one of your licensed operators at Peach Bottom, and members of the
NRC Regional and Headquarters staff to discuss events which occurred on June
10, 1985 at Peach Bottom, Unit 3.
On that day, an NRC inspector observed the
licensed reactor operator at the controls of Unit 3 with his eyes apparently
closed, thereby giving the appearance of being inattentive to his duties as a
These events are documented in NRC Inspection
licensed reactor operator.
Report No. 50-278/85-22 dated June 18, 1985.
/
,
Attheenforcementconference,theophratormaintainedthathewasnotasleep
However., he
and not inattentive to his duties, but only relaxing his eyes.
-
acknowledged that he exercised poor judgment ~ in' maintaining his appearance once
,
he was aware of the NRC inspector in the control room.
During the enforcement
conference, you described your investigation of these events, and your actions
We were impressed by' the cander of the operator
taken to prevent recurrence.
Accordingly,
j
and your thorough investigation and initiation of corrective actions.
no enforcement action is planned against you or the licensed operator regarding
j
these events.
However, based upon conversations with my staff, I concur with your finding
that a negative attitude toward the NRC by some of the licensed operators at
Although you acknowledged
]
Peach Bottoe. may have contributed to these events.
the importance of your personnel maintaining a positive attitude in dealings
with the NRC, PEco apparently has not been totally successful in fostering such
We expect the actions that you described at the enf orcement
3
Please document these actions in a
an attitude.
conference should improve this attitude.
written response to Region I within 30 days of the date of thir letter.
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The response requested by this office is not subject to the clearance
procedures of the Office of Managersent and Budget, as required by the Pa
Reduction Act of 1980, PL 96-511.
Sincerely,
-
'
Thomas E. Murl_,
Regional Administrator
cc:
R. S. Fleischmann, Station Superintendent
John 5. Kemper, Vice President, Engineering and Research
Troy B. Conner, Jr. , EsquireA. J. Pietrofitta, General Manager, Power Produ
'
Eugene J. Bradley, Esquire, Assistant General Counsel (Without Report)
Electric
Raymond L. Hovis, EsquireThomas Magette, Power Plant Siting, Nuclear Eva
Public Document Room (POR)
Local Public Document Room (LPOR)
Nuclear Safety Information Center (NSIC)
NRC Resident Inspector
Commonwealth of Pennsylvania
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NUCLEAR REOULATORY commmvev
J. Allan
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J. Gutierrez /
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R. Starostecki
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Docket No.
55-8685
License No. OP-6048-1
EA 85-75
._
_
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Mr. Lloyd-0. Givler
Box 179
Delta, Pennsylvania 17314
Dear Mr. Givier:
i
SUBJECT:
ENFORCEMENT CONFERENCE
On June 23, 1985, an enforcement conference was conducted with you, your
employer (Philadelphia Electric Company) and member s of the NRC Region I and
Office of Inspection and Enforcement Headquarters staff to discuss the events
On
which occurred on June 10, 1985 at the Peach Bottom Atomic Power Station.
that day, an NRC inspector observed you in the Unit 3 control room with your
eyes apparently closed, thereby giving the appearance of being inattentive
to your duties as a licensed reactor operator.
notwithstanding your
l
During the enforcement conference you maintained that,
l
appearance, you were not asleep and not inattentive to your duties, but were
However, you indicated that you were aware that an
'
only relaxing your eyes.
'
NRC inspector was in the control room, and that your appearance had given the
NRC inspector the impression that you were asleep, yet you did not change your
by
Further, you acknowiecged that you exercised ocor judgment
mainta ning that demeanor until confronted by your shift suDerv sor after he
i
demeanor.
These actions and your
was acvised of your cor.dition by the NRC inspector.
ne time of this
f ailure to explain you*self to the inspector or supervisor atlack of appreciation for the!
incident demonstrated an apoarent
in ove-seet ng licer.sec act vities.
4
act iers of June 10, 1985
conferen:e, you apologized f or your
At the enforcement
We acknowleoge anc
relat;ve to your attitude towards the NRC inspector.
openress anc :ancor at the enforceme-; cen#e-er:e 3n cescriting
co cenc your
acmittec exercise o# occ- jsdgment on
tne circumstantes ss-r:anc
.g your
June IC, 1955. he ex:e:
.e.a t you will maintain suct oce- e s anc canco-
inspectors.
in your f uture dealings *$ tn tne NRC anc, in particuiar, w in A;;
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' Lloyd D. Givier
'
The NRC does not intend to take enforcement action against you or Philadelphia
Further, no response to this letter
Electric Company regarding these events.
However, if your have any questions, feel free to contact us.
is required.
Sincerely,
,,
.
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Thomas E. Murley
1
Regional Administrator
cc w/ enc 1:
R. S. Fleischmann, Station Superintendent
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PHILADELPHIA ELECTRIC COMPANY
2301 MARKET STREET
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P.O. BOX 8699
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PHILADELPHI A. PA.19101
inssi e45.sooi
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August 16, 1985
'
Docket No. 50-278
.
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Dr. Thomas E. Murley, Administrator
Region I
U.S. Nuclear Regulatory Commission
631 Park Avenue
~
King of Prussia, PA
19406
1
SUBJECT:
Enforcement Conference
(Inspection 50-278/85-22)
"
Dear Dr. Murley:
4
This letter provides the documentation requested in your
letter of July 17, 1985 in reference to the Enforcement
Conf erence held on June 2t,-1985-to diseuss-events which occur red
-
on June 10, 1985 at. Peach Bottom Unit 3.
investigation of the NRC Inspector observing a
Our
licensed reactor operator at the controls of Unit 3 vith his eyes
apparently closed, thereby giving the appearance of being
inattentive to his duties, resulted in our finding that attitude
toward the NRC by some of the licensed operators at Peach Bottom
may have contributed to this event.
The actions we have taken as a result of our
investigation are described in the remainder.of this letter and
recurrence of any
are expected to improve attitude and prevent
similar event.
The following actions were taken to improve attitude and
communication:
tALShif t
Superintendents and descrijinq_sibilities of
A letter emphasizing the respon the pr of essional behavior
(1)
expected of operators at Peach Bottom was issued by ThT
Oper ations Engineer to Shif t Superintendents on June 18,
1985.
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August 16, 1985
.
Dr. Thrano E. Murlo)
Paga 2
.
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On June 19, 1985, specific written instructions were
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(2)
issued to the Nuclear Training Staff to emphasize the
j
requirements of 10 CFR 19.14 and 10 CFR 19.15 by using
8
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'
"YOU MUST CONDUCT YOURSE* F IN A
verbatim the statement,
RESPONSIBLE AND PROFESSIONAL MANNER AT ALL TIMES WHILE
ON SITE, INCLUDING COMMUNICATIONS WITH SUPERVISION,
r
MANAGEMENT, OTHER MORK GROUPS / DEPARTMENTS AND
l
in
REPRESENTATIVES OF THE NRC OR OTHER AGENCIES",
j
General Employee Training (GET) and our Nuclear
Professionalism (NUPRO) classes.
The Nuclear Plant Rules were reissued by the
of the Nuclear Generation Division on
I
(3)
.
Superintendentto include the statement above as the
July 25, 1985
first General Rule.
A letter addressing conduct of operations was issued on
June 20 to 'all licensed personnel and license trainees
(4)
This letter referenced 10 CFR
by the Plant Manager.19.15 which delineated the requirements for consultation
Included with the
with workers during inspections.
letter was a copy of IE Information Notice No. 79-20,
"NRC Enforcement Polfcy-NRC Licensed Individuals"; and a
copy of IE Circular No.81-02j "Per formance of NRC
Licensed Individuals While On Duty".
I
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A letter f rom the Peach Bottom Superintendent-Operations
(5)
to Shif t Superintendent, Shif t Supervisors, and other
Senior Licensed Operators (SLO ' s) was issued on June 20,
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addressing responsibilities of Shif t Supervisory
personnel and reminded them of Shitt Supervisory
i
responsibilities as required by Technical Specification 6.1.2 and NUREG-0737, Item I.A.1.2.
A revised copy of a
directive from the Vice President, Electric Production
Nuclear Generation
Depar tment ,' to the Super intendent ,
Division, emphasizing the primary management
Supervisory personnel for
responsibilities of the Shif t
saf e operation of the plant under all conditions on his
and clearly establishing his command duties was
shift
attached to the letter.
The recipients of the letter
were requested to review the letter and attachment to
and
reinforce their knowledge of their duties
that appr opr i ate
r esponsibilities , and assure
the
subordinates are informed of pertinent par ts of
letter.
l
As a result of our concern that shift work, in itself,
l
may be a cont ributor to individuals irritability and attitude,
and because of a belie f that irritability and negative attitude
in general may result 'com fatigue induced by long working hours
,
. .. .
.
_ - _ _ - _ _ _ _ _ _ _ _ _ _ - - _ _ _ _ - _ - - _ _ - - _ _ _ _ _
_ _ _ _
. _ _ _ _ _ _ _ - _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ - _ _ -
.
.
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August 16, 1985
. Dr'. 'Thousa E. . Muricy-
Paga 3
'
'
'and , shifting work schedule, we undertook the following actions
' T
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Working hours history of shift positions were
investigated and it was found that there were deviations
(1)
from.cer.11mit of 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> worked during a seven-day
~
Working beyond this limit is permit.e'd if .
period.
Documentation of the
approved by plant. management.
is also
approval, including an explana. tion of the cause,
Although records where kept' as to
r equ ired .
individual's work, the specific approval and
documentation of the approval was not completed due to
The procedure for
administrative oversight.
implementing this work rule is Administrative Procedure
Although the failure to document is viewed as
A-40.
minor, it did present the possiblity. of - increased
The Operations Engineer
fatigue and irritability. 1985.to Shif t Supervision
issued a memo on June 19,
calling these findings to their attention and stressing
their responsiblity for complying with procedure A-40.
The Electric Production Quality Assurance Division
(2)
performed an audit of working hour restrictions
The
implementation for all groups requiring such rules.
results of the audit were forwarded to appropriate
~
senior staf f members and exit conferences have been
Corrective acitons are being implemented.
held.
to be conducted at Limerick Generating
A pilot progr am, Station, has been initiated which is directed towards
(3)
improving the ef fectiveness and well being of shif t
This program is under the direction of a in
operators. nationally recognized pshycologist who is an expertis expecte
It
human circadian relationships.
schedule
program will provide advice relating to shif t
and work rules, as well as providing workers with
information concerning dietary and sleep patterns
It is
directed toward promoting their well being.
the benef its of this progr am and ,
as a
expected that
minimum the educational portion, will be ef fectively
a later
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incorporated into the Peach Bottom operation at
date.
On August 12, 1985, the Superintendent of Nuclear
Generation issued a letter to the Peach Bottom Plant
(4)
and the Limerick Plant Manager r estricting
This directive prevents
Manager
working successive days.
seventeen days
working certain key pe r sonnel mor e than
without a day off for rest.
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August 216, 1985
Dr'. Thom20 E. Murlwy
Pcga 4
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,
The letter reiterates our concern for the attentiveness,
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attitude, and degree of irritability effects of
excessive consecutive days of, work.
.
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On July 22, 1985 and unrelated to this event,
President and Chief Oper.ating Of ficer of Philadelphia Electric
Company received a letter from the NRC Executive Director for
Operations transmitting Information Notice No. 85-53,
This
" Performance of NRC-Licepsed Individuals While on Duty".
communication highlights an NRC concern relative to distracting
alcohol, drug abuse,
activities such as the use of radios, TV,
is not directly job
games, horseplay, hobbies, and reading thatA copy of the NRC lette
related.,
of Nuclear
given to Station Managers and the Superintendentproper attention is focu
Training to assure that
appropriate action is taken.
Commission concerns and that
We believe that the above actions will help improve
We
attitude and preclude recurrence of similar events.
and
appreciate the Regional Of fice's response to our conductof the
the Enforcement Conference and the assessment
thorough investigation and corrective actions that we initiated.
candor at
.
this incident ever occurred; however, the
We regret that
lessons learned from it will no doubt improve our performance.
Very truly yours,
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cc:
T.
P.
Johnsen, Site Inspector
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J. Allan
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B. Kane
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B. Johnston
T. Martin
J. Gutierrez
i R. Gallo
D. Holody
P.' Lohaus
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UNITED STATES
K. Abraham
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NUCLEAR REGULATORY C0m!$$10N
.C. Cowgill
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3/31/87-TEM
in the Matter of.
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Docket Nos. 50-277;50-278
PHILADELPHIA ELECTRIC COMPANY
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License Nos. OPR-44; OPR-56
^
EA 87-46
Peach Sottom Atomic Power Station,
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Deits 2 and 3
)
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ORDER SUSPENDING POWER OPERATION AND
ORDERTO5HOWCAUSE(EFFECT!YEIMEDIATELY)
I
Philadelphia Electric Company (Licensee) is the holder of Facility Operating
License Nos. OPR-44 and DPR-56, authorizing the Licensee to operate the Peach
.
Bottom Atomic Power Station, Units 2 and 3 (facility), in Delta, Pennsylvania.
1
The licenses were issued by the Nuclear Regulatory Commission (NRC or
Comission) on OctobirFh5,"1973 siiN} 2519N, respectively.
-
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On March 24, 1987, the NRC, Region I, received information that control room
operators at Peach Bottom had been observed sleeping while on duty in the
control room and were otherwise inattentive to their license obligations. The
information also indicated that this conduct on the p1rt of operators was
)
pervasive and has been occurring for some time, and that shift supervision
had knowledge of this situation. On March 24. 1987, in response to this
infomation NRC initiated:
(1) 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> inspection coverage of the Peach
'
Bottom control room and (2) a special safety investigation of licensed
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activities. The NRC investigation, which is still ongoing, to date has
established:
.
.
1.
At times during various shifts, in particular the 11:00 p.m. to 7:00
a.m. shift, one or more of the Peach Bottom operations control room
staff (including licensed operators, senior licensed operators and
shift supervision) have for at least the past five months
l
periodically slept or have been otherwise inattentive to licensed
duties.
2.
Management at the Shift Supervisor and Shift Superintendent level
have either *known and condoned the facts set forth in Paragraph one,
,
I
or should have known of these facts.
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3.
Plant management above the shift superintendent position either knew
or should have known the facts set forth in Paragraph one and either
took no action or inadequate action to correct this situation.
'
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Prior NRC inspections have identified other instances of inattention to duty or
i
failure to adhere to procedures on the part of licensed operators in the control
room at Peach Bottom.
.
On June 10, 1985, during the 11:00 p.m. to 7:00 a.m. shif t, an NRC inspector
was present in the Unit 3 control room and observed an on. duty Unit 3 reactor
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operator sitting in a chair at the Unit 3 reactor control panel with his eyes
closed and his head tilted back, apparently asleep or.otherwise inattentive to
his duties.
In response to this charge the licensed operator denied being
asleep and indicated he was enticing the NRC inspector to believe he was
asleep. . demonstrating poor judgment and a negative attitude toward safety. An
enforcement conference was held with the licensee concerning this matter on
June 21, 1985.
On June 6, 1986, the NRC issued its Systematic Assessment of Licensee
Perforinance (SALP) report for the period April 1,1985 through January 31,
1986. This report concluded that management involvement and effectiveness
-
toward improving operating activities was not evident.
Indications of the lack
of adequa,te management, involvement included:
poor dissemination of managemeds>
goals and policies; poor commurications between different departments and
!
divisions; and a focus on compliance rather than acknowledgement and correction
of the root causes of problems.
Further, the report concluded there was a
complacent attitude toward procedural compliance in plant operations.
On June 9,1986,'the NRC issued a Notice of Violation and Proposed $200,000
Civil Penalty for several violations that resulted from numerous personnel
i
errors by several licensed operators, including the Shift Supervisor and Shift
Superintendent, both of whom are licensed senior reactor operators, and two
licensed reactor operators. These personnel errors by four licensed
'
individuals and associated violations indicated a pattern of inattention td
detail, failure to adhere to procedural requirements, and a generally
'
complacent attitude by the operations staff toward performance of their duties
g
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at peach Bottom. This NRC assessment was emphasized to the licensee in a
June 12, 1986, letter from Victor Stello, Jr., taecutive Director for
Operations, to J. C. Everett I!!, PEco Chairman of the Board and Chief
Executive Officer.
In addition, three previous civil penalties were issued for violations of
technical specifications involving violations that resulted from personnel
errors. March 29,1983 (EA 83-7); June 13,1983 (EA 83-46); June 18,1964 (EA
54-33).
In general, the enforcement history at Peach Bottom regarding
adherence to procedures and attention to duty has been poor.
.
IV
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b - The NRC expects licensees to maintain high sTEHTafd's of c5nirol room
professionalism.
NRC licensed operators in the control rooms at nuclear power
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, plants are responsible for assuring that the facility is operated safely and
within the requirements of the facility's license, technical specifications,
regulations and orders of the NRC. To be able to carry out these highly
.fsportant responsibilities, reactor operators must give their full attention to
the condition of the plant at all times. Operators must be alert to ensure
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that the plant is operating safely and must be capable of taking timely action
in response to plant conditions. All control room business must be conducted
in such a way that neither control room operator attentiveness nor the
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professional abnosphere will be compromised.
Sleepin9 while on duty in the
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control room demonstrates a total disregard for performing licensed duties and
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a lack of appreciation for what those duties entail.
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10 C.F.R. 50.54(k) and Peach Bottom Technical Specification 6.2.2 prohibit
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sleeping or otherwise inattentive operators in the control rtion. Under
10 C.F.R part 50, App. 8, the licensee sust have and implement procedures to
ensure that activities affecting quality, including operations of the facility,
are satisfactorily accomplished. The Peach Bottom quality assurance progrom
has failed to identify this condition adverse to safety. These conditions
constitute a hazard to the safe operation of the facility.
.
In light of the above, it is apparent that the licensee, through its
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enforcement history and from what has been developed by the ongoing
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investigation, knew or should have known of the unwillingness or inability of
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its operations staff to comply with Comission requirements, and has been
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unable to implement effective corrective action. Consequently, the NRC lacks
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reasonable assurance that the facility will be operated in a manner to assure
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that the health and safety of the public will be protected.
Pending the
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development of other relevant information, I am unable to determine that there
is reasonable assurance that the facility will be operated in a ianner to
assure that the health and safety of the public will be protected.
Accordingly I have determined that cc.ntinued operations of the facility is an
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indeediate threat to the public health and safety. Therefore, I have determined
that the public health, safety and interest requires that the. Licensee should
proceed to place or maintain its units in a cold condition.
I have further detemined for the reasons set forth above, that pursuant to
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10 C.F.R. 2.201(c), no prior notice is required and, pursuant to 10 C.F.R. 1
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2.202(f), the actions required by Section V of this Order are immediately
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effective pending further Order.
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Accordingly, pursuant to Sections 103,161(1)and.(o),182and186ofthe
Atomic Energy Act of 1954, as amended, and the Commission's regulations in
10 C.F.R. 2.202, and 10 C.F.R. Part 50, IT !$ HEREBY ORDERED, EFFECT!YE
I M EDIATELY THAT:
A.
The licensee shall within 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br /> from receipt of tMs Order,
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shutdown Unit 3 and place the unit in the cold condition (reactor
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coolant temperature equal to or less than 212*F) and maintain both
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units in the cold condition with the reactor mode switch in either
the refueling or shutdown mode pending further Order.
.
B.
The licensee shall provide to the Administrator of Region I within
seven days of this Order a description of the actions the licensee
plans to take to provide assurance that the facility will comply
with all reovirements including station procedures while in a cold
condition.
C.
Before the licensee proposes to operate either Unit 2 or Unit 3 above
a cold conditior the licensee shall provide to the Administrator of
Region I, for his approval, a detailed and comprehensive plan and the
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schedule to accomplish the plan to assure that the facility will
safely operate and comply with all requirements. including station
proceduress
D.
Licensee may show cause, in the manner hereinafter provided, why this
order should not have been issued; and
E.
The Regional Administrator, Region I, may relax any of the above
provisions, in writing, upon demonstration of good cause by the
licensee.
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Thelicenseemayshowcause,within20daysafterissuanceofthisOrderby
filing a written answer under oath or affirmation setting forth the matters
of fact and law on which the licensee relies. The licensee may answer as
provided in 10 C.F.R. 2.202(d) by consenting to the entry of an Order in
substantially the form proposed in this Order.
VII
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The licensee or any other person adversely affected by this Order may request a
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hearing within 20 days after issuance of this Order.
Any answer to this Order
or any reovest for hearing shall be submitted to the Executive Director for
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Operations
U.S. Nuclear Regulatory Commission, Washington, D.C.
,
20555.
Copies shall also be sent to the Assistant General Counsel for Enforcement,
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Office of the General Counsel, at the same address and to the Regional
Administrator', U.S. Nuclear Regulatory Cossiission, Region I, 631. park Avenue,
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King of Prussia, Pennsylvania 19406.
If a person other than the licensee
requests a hearing, that person shall set forth with particularity the manner
in which the petitioner's interest is adversely affected by this Order and
should address the criteria set forth in 10 C.F.R. 2.714(d). Upon the failure
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of the licensee to answer or reovest a hearing within the specified time, this
,
Order shall be final without further proceedings. An answer to this Order or a
request for hearing shall not stay the immediate effectiveness of Section V of
this Order.
.
If a hearing is requested by the licensee or other person adversely affected by
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this Order, the Comission will issue an Order designating the= time and place -
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of any hearing.
If a hearing is held, the issue to be considered at such
hearing shall be whether this Order should be sustained.
FOR THE NUCLEAR REGULATORY C0P96!5510N
>_
ictor t
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Executive Director for Operations
Dated at Bethesda Maryland
this,34, day of March,1987
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PHILADELPHIA ELECTRIC COMPANY
2301 MARKET STREET
P.O. BOX 8699
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PHILADELPHI A. PA,19101
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taist s4i 4soo
. April 6, 1987
"
JOHN S. MsMPsa
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.e.s. io..n..v es.s.+.=.ss.a..n...nt. -
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Docket Nos'. 50-277
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50-278
License Nos. DPR-44
DPR'56
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Dr.. Thomas E. Murley,~ Administrator
Region I'
U.S. Nuclear Regulatory Commission
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ATTN: Document Control Desk'
Washington, D.C.
20555
SUBJECT:
Order Suspending Power Operation
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Peach Bottom Atomic Power Station. Units 2 and 3
Dear Dr. Murley:
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In accordance with Section V.A of the Order, dated March
31, 1987 suspending power operation of Peach Bottom Atomic Power
Station Units 2 and 3, a Unit 3 shutdown was initiated at 1147
hours on March 31, 1987 and cold conditio~n was achieved at 0010-
hours on April 1, 1987'..
Unit 2 has'been.in a refueling outage
and_is-being maintained in cold condition.-
d
In accordance with Section V.B of the Order, a
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description of the actions licensee has taken and plans to take
to~ provide assurance that the facility.will comply with all-
requirements including station procedures while in a cold
condition follows.
1.
Licensee is establishing 24-hour coverage of. operations-
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by at~1 east one independent, nuclear experienced
engineer or physicist'per shift who will be posted-
within the control room complex to observe licensed
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duties and report directly to the Superintendent of
Nuclear Operations Quality Assurance Division at the
Corporate Headquarters.
If it becomes necessary for
this individual to leave the control room complex for a
brief period, his functions will be assumed by the Shift
Technical Advisor during his absence. .The function of
these individuals will be to verify that licensed
personnel are alert and professional in the manner they
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Dr.'Thomes E.LMurley
April 6, 1987
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conduct' licensed duties in accordance with commission
requirements and station procedures.
This 24-hour
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coverage will be in place by April 11, 1987.
2.
Immediately after receipt of the Order, Senior Plant.
Management began making unannounced visits to the
control room'during each night shift (2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br /> to 0700
hours).. This activity will continue until the
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additional 24-hour coverage of operations by the special
monitoring team is established, at which time the
frequency of these visits will be reduced..
3.
An administrative block'which ensures the shutdown
conditions are, maintained'was applied on March 31, 1987
at 1730 hours0.02 days <br />0.481 hours <br />0.00286 weeks <br />6.58265e-4 months <br />. . This block requires the mode switch of
each unit to be in the SHUTDOWN or REFUEL position.to
ensure compliance with the Order.
Removal of the block
requires'the approval of the Plant Manager or the
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Superintendent-operations.
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4.
Meetings chaired by the Plant Manager have been: held
with control room operating shift personnel, beginning
on. March 31, 1987, to discuss the Order and events
leading to the Order. .During these meetings, it was
forcefully restated'that sleeping or the appearance of
sleeping at their posts is unacceptable and will result
in immediate suspension from duty with recommendation
for termination of employment.
Personnel were urged to
be open, frank, and candid during interviews with the
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NRC on.this subject.
5.
Special meetings, in addition to the above meetings,
have been held with Shift Superintendents and Shift
Supervisors (senior licensed operators).
In these
meetings Shift' Supervision was forcefully reminded by
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the Plant Manager that it was their responsibility to
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ensure.that personnel on their shift remain attentive
and alert and to take appropriate action if this is not
the case.
Furthermore, they were informed that if they
received reports of such situations concerning other
shifts or individuals that those reports should be
forwarded to Senior Plant Management for disposition.
6.
Upon receipt, the Order was posted at the station and a
summary was issued via a station newsletter.
Subsequently, a copy of the Order was distributed to all
control. room personnel.
7.
The Peach Bottom Operations Engineer has been reassigned
to Corporate Headquarters effective April 6, 1987 and
has been replaced with another nuclear experienced,
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qualified engineer holding a senior operator license at
the Peach Bottom station.
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Dr. Thom2s E. Murley
April 6, 1987
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Page 3
8.
'The.following human factor related changes have been
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made to the control room to make the' operators more
observable by the Shift Supervisor.
The Shift
Supervisor's post in the control room has been elevated
to give him a better view of the room and the operators.
Additionally, the high-back chairs in the. control room
have been replaced with low-back chairs.
.
9.
Control room operators are being-required to record
certain key plant parameters and the decay heat removal
equipment status hourly with review and sign-off by
shift supervision to ensure that the cold condition is
safely maintained.
The recorded data will be:
mode
switch position, reactor water level and temperature,
reactor pressure, reactor head vent valves position (not
applicable if reactor head is removed), decay heat
removal equipment status (in service or standby), and
fuel pool temperature.
10.
An additional status-report to Senior Plant Management
is now required of the afternoon and night shifts.
Shortly prior to the end of these shifts, Shift
Supervision is being required to report to Senior Plant
Management the plant status and a brief synopsis of his
shift's activities.
11.
All licensed control room operators are being required
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to re-review Administrative Procedure A-7, " Shift
Operations", and I.E. Circular 81-02, " Performance of
NRC Licensed Individuals While on Duty", and sign a
statement documenting that they have read and understand
the material.
If you have any questions or require additional
information, please do not hesitate to contact us.
Very truly yours,
,
cc:
Addressee
V. Stello, Jr., Executive Director for Operations, USNRC
T. P. Johnson, PBAPS Resident Site Inspector
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UNITED STATES
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NUCLEAR REGULATORY COMMISSION
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FIEGION I
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631 PARK AVENUE
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KING OF PRUSSIA, PENNSYLVANIA 19406
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12 MAY 1987
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Docket Nos. 50-277/DPR-44
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50-278/DPR-56
Philadelphia Electric Company
ATTN: Mr. J. W. Gallagher
Vice President
Nuclear Operations
2301 Market Street
Philadelphia, Pennsylvania 19101
Gentlemen:
Subject: Combined Inspection 50-277/87-10; 50-278/87-10
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This transmits the findings of the special safety inspection by Mr. T. P.
Johnson and others on March 24 to April 9, 1987, at the Peach Bottom Atomic
Power _ Station, Delta, Pennsylvania. These findings were based on observation
of activities, interviews, measurements and document reviews, and have been
discussed with Mr. R. S. Fleischmann of your staff.
A copy of this letter and the enclosures are being placed in the NRC Public
Document Room.
On March 31, 1987 NRC issued an immediately effective order which required you
to place both Units in a cold condition. At the time Unit 3 was operating.
We note that Unit 3 was promptly shut down and placed in the cold condition.
Based on the results of this insi,ection, it appears that one of your activities
was not conducted in full compliance with NRC requirements, as set forth in the
,
Notice of Violation, enclosed herewith as Appendix A.
This violation has been
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categorized by severity level in accordance with the General Statement of Policy
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and Procedure for NRC Enforcement Actions, 10 CFR Part 2, Appendix C (Enforce-
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ment Policy 1986). You are required to respond to this letter and in preparing
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your response, you should follow the instructions in Appendix A.
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'During this inspection, we noted several concerns associated with operator
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watch standing practices.
These concerns are discussed in detail in the
We have
attached report and are considered unresolved issues at this time.
summarized these issues in Appendix B.
In accition to tne response required
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by Appendix A, we request that you respond to the concerns identified in
Appendix 8.
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,' Philadelphia Electric Company
2
12 MAY 1987
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Your cooperation with us is appreciated.
Sincerely,
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William F. Kane, Director '
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Division.of Reactor Projects
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Enclosure:
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Appendix A, Notice of Violation
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2'
Appendix B, Operator Watch Standing Concerns
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3.
NRC Region I Combined Inspection Report No. 50-277/87-10 and
50-278/87-10
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cc w/encis:
R. S. Fleischmann, Manager, Peach Bottom Atomic Power. Station
John S. Kemper, Senior Vice President, Engineering and Production
W. H. Hirst, Director, Joint Generation Projects Department,' Atlantic
Electric
G. Leitch, Nuclear Generation Manager
Troy B. Conner, Jr. , Esquire (Without Report)
Eugene J. Bradley, Esquire, Assistant General Counsel (Without Report)
Raymond L. Hovis, Esquire (Without Report)
Thomas Magette, Power Plant Siting, Nuclear Evaluations
W. M. Alden, Engineer in Charge, licensing Section
Public Document Room (PDR)
local Public Document Room (LPOR)
Nuclear Safety Information Center (NSIC)
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NRC Resident Inspector
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Commonwealth of Pennsylvania
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bcc w/ enc 1:
Region 1 Docket Room (with concurrences)
Management Assistant, DRMA (w/o encl)
M. Shanbaky, Chief, FRPS, DRSS
SRI, Limerick I
W. Russell
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APPENDIX A
Docket Nos. 50-277; 50-278
PhiladelphiaEiectricCompany. .
Peach Bottom Atomic Power Station
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Unit 3
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During an NRC inspection conducted from *,.ch 24 to April 9, 1987, a
violation was identified in accordance with the NRC Enforcement Policy (10 CFR 2, Appendix C). The particular violation is set forth below:
-Technical Specification section 6.8.1 requires that written
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procedures be established, implemented, and maintained that meet
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A.
the requirements of sections 5.1 and 5.3 of ANSI N18.7-1972, and
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Appendix A of Regulatory Guide 1.33 (November 1972).
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ANSI N18.7-1972, section 5.3.4.2 requires procedures for plant
shutdown, including decay heat removal.
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(November 1972) Appendix A, section C, requires operating
procedures for shutdown. cooling systems.
Procedure S.3.2.C.1 " Shutdown Cooling Mode - Manual Start and
28, 1986 step #7 requires that prior
Shutdown", Rev. 17, dated May
to place RHR in service the loop is flushed by operating selected
valves in a specific order.
Contrary to the above, at approximately 9:25 p.m., on March 31,
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1987, on Unit 3, procedure S.3.2.C.1, step 7 was not performed in the
required order resulting in a high pressure primary containment
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isolation system actuation.
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This is a Severity Level IV violation (Supplement 1).
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Pursuant to the provisions of 10 CFR 20.201, Philadelphia Electric Company
is hereby required to submit to this office witin 30 days of the date of the
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letter transmitting this Notice, a written statement or explanation in reply
including for each violation:
(1) the reason for the violation if admitted,
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(2) the corrective steps which have been taken and the results achieved, (3)
the corrective steps which will be taken to avoid further violations, and
(4) the'date when full compliance will be achieved. Where good cause is
shown, consideration will be given to extending the response time.
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APPENDIX B
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OPERATOR WATCH STANDING CONCERHS
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Docket Nos.
50-277; 50-278
Philadelphia Electric Ccmpany
Peach Bottom Atomic Power Station
Units 2 and 3'
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' Observations made by shift inspectors that relate to informal operator
fl.
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watch _ standing practices are 11'sted below and discussed in detail in the
inspection report,
Coffee cups and soda cans sitting on.various control panels,
a,
b.
Operators with their feet up on the domputer console and leaning
back in their chair giving a perception of inattention,
Lack of knowledge of the status of the Unit 3, number three turbine
c.
control valve on March 27, 1987.
d.
Unnecessary prolonged bypassing of APRM channel E on March 30, 1987.
Attemptingnto defeat interlock to start Unit 3 RHR pump 3B while Unit
e.
-2 RHR pump 2B was in service on March 31 - April 1.
f.
Operation of equipment on March 27, 1987 by non-shift (bat licensed)-
personnel without the supervision of the assigned licensed
i operator,
Lack of guidelines on what constitutes " attention to duty".
g.
Operator inattentiveness to instrumentation on Unit 3 prior to the
h.
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March 17, 1987 scram.
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a. nuncan neuvi.navn curm aa tun
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REGION I
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' Report No.'50-277/87-10 & 50-278/87-10
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Docket No. 50-277'& 50-278
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Licensee: .Phila'delphia Electric Company
2301" Market Street
Phi ~adelphia, Pennsylvania 19101
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Facility _Name: Peach Bottom Atomic Power Station Units 2 and 3
Inspection At: Delta, Pennsylvania
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Inspection Conducted: March 24,_1987 to April 9, 1987
Inspectors:
T.. P. Johnson, Senior Resident Inspector, Peach Bottom
C. C. Warren, Senior Resident Inspector, Shoreham
M. G. Evans, Reactor Engineer, DRS
L. E. Briggs, Lead Reactor Engineer, DRS
R. J. Urban, Resident Inspector, Peach Bottom
B. M. Hillman, Reactor Engineer
L. L. Scholl, Reactor Engineer.
J._ F. Wechselberger, Resident Inspector, Oyster Creek
D. K. Allsopp, Resident Inspector, Hope Creek
S. V. Pu11ani, Fire Protection Engineer, DRS
L. J. Wink, Reactor Engineer, DRS
D. J. Florek, Lead Reactor Engineer, DRS
J. A. Prell, Reactor Engineer, DRS
F. J. Crescenzo, Reactor Engineer Examiner
Reviewed By:
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J. H. Willi @, Pr6 ject Engineer
date
Projects Section 2A
79
Reviewed By:
C. J. Cowgi%L) Acting Chief, Reactor
date
Projects Section EA
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Approved By:
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acter Project
W. 41 allo, Ch
ranch 2,
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Division of Reactor Projects
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Sustained and continuous control room and plant observa-
Inspection Summary:
Periodic control room and plant observa-
tions from March 24 to April 2, 1987. Followup on Unit 3 scrams on, March 17 and
tions f rom April 2 to April 9,1987.
EHC troubleshooting activities; Unit 3 startup, power ascension and
25, 1987;
Observations of selected surveillances.
Review of. Unit 2
testing activitie's.
refueling activities.
(Five hundred and thirty total hours (Unit 2 and 3))
One violation (section 8.4) for failure to follow shutdown cooling
Results:
Observations of control room operators' attentiveness led to
procedure.
unresolved items associated with operator watch standing practices.
(Sections 4.3, 4.4'and 8.1)
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DETAILS
1.
Background
17, 1987, Unit 3 auto scrammed from APRM high-high flux caused
On March
The root
by pressure spikes due to turbine control valve fluctuatio.ns.c
When no problems
shutdown for.four days to troubleshoot the EHC system.
were'found in the EHC system while in a cold static condition, the
licensee restarted Unit 3, with NRC Region I concurrence, to troubleshoot
the EHC system while in a hot dynamic condition.
On March 21, 1987, when Unit 3 reached approximately 2% power, the
licensee noted similar- EHC system fluctuations that had caused the
scram on March 17, 1987. By March 24, 1987, the licensee had still not
identified the root cause of the scram. Also, on this same day, NRC
Region I received information that control room operators at Peach
Bottom had been observed sleeping while on duty in the control room and
At this
were otherwise inattentive to their license obligations.
point, NRC Region I management dstermined that sustained control room and
plant observation was needed while pursuing substantiation of the
information.
Region I instituted arouad-the-clock coverage of
On March 24, 1987,
The inspection objective was to provide regional
licensee activities.
management an opportunity to evaluate the licensee's control room and
Of specific concern were
plant performance over a sustained period.
On
licensed operator activities and EHC system troubleshooting.NRC o
March 31, 1987
This was completed at 2335 on March 31.
proceed to cold condition.
Around-the-clock coverage was suspended on April 2,1987, at the end of
the afternoon shift (3:00'p.m. to 11:00 p.m.).
2.
Inspection Methodology and process
24, 1987, with a continuous review of
The inspection began on March
plant activities by one to three region based or resident inspectors on
a three shif t rotation (7:00 a.m. to 3:00 p.m. ; 3:00 p.m. to 11:00 p.m
11:00 p.m. to 7:00 a.m.).
April 3, 1987, with additional hours devoted to backshift and weekend
tours by the residents and a region based inspector.
Areas inspected during this period included NRC licensed operator shif t
activities, including surveillance test observations and Unit 2
refueling operations quality assurance / quality control coverage of
control room activities, EHC system troubleshooting, plant events that
occurred during the inspection period, and LER cause analysis.
The inspectors used the following criteria during their reviews:
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Operators are attentive and responsive to plant parameters and
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conditions.
Plant _ evolutions and testing are planned and properly authorized.
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Procedures are used and followed as required by plant policy.
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Equipment status.c'hanges are appropriately documented and
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communicated to appropriate shift personnel.
The operating conditions of plant equipment are effectively >
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monitored, and appropriate corrective action is initiated when
required.
Backup instrumentation, measurements, and readings are used as
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appropriate when normal instrumentation is found to be defective
or out of tolerance.
Logkeeping is timely, accurate, and adequately reflects plant
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activities and status.
Operators follow good operating practices in conducting plant
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operations.
The inspection findings are discussed in the following paragraphs.
3.
Persons Contacted
"J. B. Cotton, Superintendent Plant Services
- A. B. Donnell, Site QA Supervisor
- R. S. Fleischmann, Manager, Peach Bottom Atomic Power Station
A. A. Fulvio, Technical Engineer
J. A. Jordan,~Results Engineer
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A. E. Hilsmeier, Senior Health Physicist
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J. F. Mitman, Radwaste Engineer
D. L. Oltmans, Senior Chemist
- K. N. Mandl, QA Corporate Supervisor
J. P. McElwain, Site QC Supervisor
"F. W. Polaski, Operations Engineer
S. R. Roberts, Operations Engineer
- D. C. Smith, Superintendent Operations
J. E. Winzenried, Staff Engineer
Other licensee employees and licensed operators were also contacted.
- Present at exit interview on site for summation of preliminary
findings.
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4.
Shift Operations Review and Observations
4.1 R_ontine Observations
The in'spectors observed plant operations dur'ing tours each shift.
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Thefollowingareaswereinspge'ad:
p
ControlRoom(essentiall)
time for certain periods as
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previously noted)
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Cable Spreading Room
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Switchgear and Battery Rooms
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Reactor Buildings
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Turbine Buildings
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Radwaste Building
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Recombiner Building
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Pump House
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Diesel Generator Building
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Protected and Vital Areas
Security Facilities (CAS, SAS, Access Control,' Aux SAS)
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High Radiation and Contamination Control Areas.
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Control Room and facility shift staffing.was frequently
4.1.1
checked for compliance with 10 CFR'SO.54 and Technical
Presence of a senior licensed operator
Specifications.
!
in the ' control room was verified during each visit to the
Control Room.
(See Section 4.3 for details.)
The inspectors frequently observed that selected control
4.1.2
room instrumentation indicated values that were within
.'
Technical Specification requirements and normal operating
limits.
ECCS switch positioning and valve lineups were
-
verified based on control room indicators and plant obser-
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Observations included flow setpoints, breaker
vations.
)
positioning, PCIS status, and radiation monitoring in-
struments.
Selected control room off-normal alarms (annunciators)
1
4.1.3
were discussed with control room operators and shift
'
supervision to assure they were knowledgeable of alarm
status, plant conditions, and that corrective action, if
required, was being taken.
In addition, the applicable
alarm cards were checked for accuracy. The operators
were knowledgeable of alarm status and plant conditions.
j
4.1.4
The inspectors checked for fluid leaks by observing sump
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status, alarms, and pump-out rates; reactor coolant
system leakage was discussed with licensee personnel.
.
.)
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5
4.1.5
Shif t relief and turnover activities were monitored .
each_ shift while on co'ntinuous control room coverage,
and periodically thereafter, to ensure compliance with
.
administrative procedures and regulatory guidance.
4.1.6
The inspectors observed the main stack and both reactor
building. ventilation stack radiation monitors and
recorders, and periodically reviewed, traces from
backshift periods to verify that radioactive gas release
rates were within limits and that unplanned releases had
not occurred.
4.1.7
The inspectors observed control room indications of fire
detection instrumentation and fire suppression systems,
monitored use of fire watches and ignition source
controls, checked a sampling of fire barriers'for
integrity, and observed fire-fighting equipment
stations.
f
4.1.8
The inspectors observed overall facility housekeeping
conditions, including control of combustibles., loose
trash and debris.
Cleanup was spot-checked during and
Plant housekeeping was generally
after maintenance.
<
acceptable.
4.1.9
The inspectors observed the nuclear instrumentation
subsystems (source range, intermediate range and power
range monitors) and the reactor protection system to
verify that the required channels were operable.
4.1.10
The inspectors frequently verified that the required
'
off-site electrical power startup sources and er.crgency
j
on site diesel generators were operable.
A loss of #3
startup source occurred on April 7, 1987 (see section
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>
11.5).
1
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The inspectors verified operability of selected safety
4.1.11
related equipment and systems by in-plant checks of
valve positioning, control of locked valves, power
)
supply availability, operating procedures, plant
j
drawings, instrumentation and breaker positioning.
Selected major components were visually inspected for
leakage, proper lubrication, cooling water supply,
No
operating air supply, and general cunditions.
J
The
significant piping vibration was detected.
inspector reviewed selected blocking permits (tagouts)
for conformance to licensee procedures.
No inadequacies were identified.
4
6
4.2 Logs and Records
The inspectors reviewed logs and records for accuracy, co.mpleteness,
abnormal conditions, significant operating changes and trends,
required entries, operating and night order propriety, correct equip-
ment and lock-out status, jumper log validity, conformance to
The
Limiting _ Conditions. for Operations, and proper reporting.
following logs and records were rev'fewed:
Shift Supervision Log,
Reactor Engineering Logs, Unit 2 Reactor Operator's Log, Unit 3
Reactor Operator's Log, Control Operator Log Book and STA Log Book,
Hight Orders, Radiation Work Permits, Locked Valve Log, Maintenance
Request Forms. Temporary Circuit Modification Log, and Ignition
Source Control Checklists.
Control Room logs were compared against
Administrative Procedure A-7, Shift Operations.
Frequent initialing
of entries by licensed operators, shift supervision, and licensee
'
No
on-site management constituted evidence of licensee review.
unacceptable conditions were identified.
4.3 Operator Alertness
.
The on-shift inspectors observed control room demeanor, operator
i
alertness and attentiveness, and compliance with other requirementsThe
for operator performance as stated in section 4.4 of this report.
inspectors did not observe any licensed operators sleeping while on
No observations of operators reading non job-related material
duty.
occurred.
The inspectors did not observe any non job-related
reading material in the control room.
However,
{
Operators were' alert and generally attentive to duties.
the following observations were made by shift inspectors regarding
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operator watchstanding practices:
Several instances of coffee cups and soda cans sitting on
--
varinus control panels were noted.
l
At times, the reactor operators were observed with their feet
--
up on the computer console and leaning back in their chair,
giving a perception of inattention.
'
27, 1987, at approximately 5:30 p.m., when the chief
On March
operator selected shell warming, he did not notice the position
--
of the Unit 3 Number 3 turbine control valve (TCV). System
19,
procedure S.6.3.1. A, " Main Turbine Generator Start-Up", Rev.
requires the operator to check that tne TCVs are fully open. On
at approximately 2:30 a.m.,
the shift superin-
March 27, 1987,
tendent and supervisor noticed that the Number 3 TCV was closed.
The test engineer responsible for EHC troubleshooting stated He
that the EHC system had not been touched for several days.
also stated that the logic card for the Number 3 TCV was pro-
bably damaged two days earlier during troubleshooting.
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On Unit 3 at 10:00 p.m. on March 30, 1987, average power
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range monitor (APRM) "E" remained bypassed unnecessarily
for about 30 minutes after the reactor engineer completed
'
troubleshooting a failed LPRM. APRM "E" was subsequently re-
i
turned to service. Technical Specifications Table 3.1.1
j
require at least two operable APRMs per RPS channel.. The
1
inspector verified that APRMs "A" and "C" were * operable.
Duringthe11:00'p.b.to7:00a.m.shiftonMarch31-April
---
1, 1987, the Unit 3 RHR pump 3B failed to. start after two
attempts when initiating the RHR shutdown-' cooling mode.
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!
After troubleshooting, the on-shift operators determined that
'
the cause for failure to star.t was that the equivalent Unit 2
RHR pump (28) was in service in the shutdown cooling mode. The
two RHR pu.nps (28 and 38) powered from the same diesel generator
are interkcked so that only one may be run at a time. Ap-
parently, neither the Unit 3 reactor operator nor the control
room shift supervisor realized this fact.
Failure to follow the shutdown cooling operating procedure on
--
March 31, 1987, resulted in a group IIB primary containment
i
isolation.on Unit 3.
This is an apparent violation.
(See
Section 10.4).
On March 27, 1987 between 4 and 5 p.m. , a senior licensed
--
individual not on the shift watch list was observed operating
. equipment on the Unit 3 console.
The individual did not appear
to be under the supervision of the assigned licensed operator.
These above items except for the apparent violation are collectively
grouped as an unresolved item (UNR/277/87-10-01; 278/87-10-01)
l
4.4. Administrative Requirements for the Performance of NRC-Licensed
Individuals Whil,e on Duty
The requirements and guidelines for the on duty performance of NRC
licensed individuals is addressed in the following documents:
10 CFR 50.54 k, m and 10 CFR 55
q
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IE Information Notice 79-20, Revision 1
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The licensee implements these items in administrative procedure A-7,
'
"Shif t' Operations", and in " Nuclear Plant Rules".
The_ inspector
reviewed these documents.
The following table summarizes the
licensee's implementation of these requirements and guidelines:
Item / Requirement
Where Implemented
Aware of and responsible for
A,7, section 7.1.6
plant status
Formal watch turnover and relief
A-7, section 7.1.5 and 7.5
Alert and attentive
A-7, section 7.1 7
Remain in areas of responsibility
A-7, section 7.1.5, 7.2
Prohibit distracting activities
A-7, section 7.1.8
No reading that is not job
A-7, section 7.18 and Nuclear
related
Plant Rules
Control Room. access limited
A-7, section 7.3
l
The inspector noted that the licensee neither administratively
l
defines what constitutes " attention to duty" nor were the licensed
control room operators able to verbally define " inattention to duty".
Appropriate procedure revisions and training upgrades to improve the
knowledge and. clarify the definition of attentiveness are needed.
This item is unresolved (UNR/277/87-10-02; 278/87-10-02).
5.
Refueling Operations
5.1 Unit 2 Core Offload
,
Unit 2 core offload began on March 23, 1987.
The inspector reviewed
licensee prerequisites for core offload.
A review of the related
refueling documentation was performed and is included in
Attachment 1.
The inspectors monitored the following items associated with core
of fload through direct observation of fuel handling activities on-
the refueling floor and in the control room.
The operability of refueling ir.terlocks,
--
The operability of source range monitoring (SRM)
--
instrumentation,
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Availability of direct communication between the control room
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and refueling bridge,
- The presence of a senior licensed operator supervis'ing fuel
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handling activities,
The operabili.ty of the standby gas treatment system and
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secondary' containment,
The radiological precautions for fuel handling including
--
adherence to the RWP,
The presence of an HP technician in the fuel floor area,
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The precautionary measures for preventing the intrusion of
--
foreign objects intb the reactor cavity.
The operation of refueling bridge and associated fuel
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1
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handling equipment,
. Reactor vessel and fuel pool water level and clarity
--
requirements,
Fuel and component. accountability in the spent fuel pool and
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in the reactor core,
Reactor mode switch locked in " refueling" position,
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The operability and required full insertion of all control
--
rods, and
Unit 2 reactor operator cognizance of refueling activities
and direct monitoring of SRM levels and changes (count rates
--
and period changes).
No violations were noted.
5.2 Stuck Fuel Assembly (49-40)
When attempting to remove Unit 2 fuel assembly 49-40 from the
reactor core, the double blade guide appeared to be caught with
An unsuccessful attempt was made to free the bundle
the bundle.
With the aid of an underwater
with special procedure SP-993.
camera, the fuel support piece was found raised out of the guide
!
Another special procedure SP-994 was used in an unsuccessful
tube.
Continued efforts to
attempt to seat the raised . fuel support piece.
seat the fuel support piece and dislodge the bundle nose piece were
The offload sequence
temporarily abandoned for engineering analysis.
was changed to allow fuel movement to continue in parallel with
resolution of this fuel assembly removal preblem.
.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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The inspector reviewed procedures SP-993 and.SP-994 and discussed
j
them with licensee engineers and operators. The inspector will
continue to follow the attempts to remove and the causes .for the
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stuck bundle.
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No violations were identifiedgr
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6.
Surveillance Testing
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The inspectors observed surveillance tests to verify that testing had
been properly scheduled, approved by shif t supervision, control room
operators were knowledgeable regarding testing in progress, approved
procedures were being used, redundant systems or components were
available for service as required, test instrumentation was calibrated,
work was performed by qualified personnel, and test acceptance criteria
i
Portions of the surveillance tests listed in Attachment 3
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were met.
'
were observed.
[
The inspector determined that test performance and results review was
good, and should be considered a licensee strength.
No inadequacies were identified.
7.
Quality Assurarice/ Quality control (QA/QC)
The Peach Bottom QA Plan Volume III, Operations Phase, Revision 5,
I
Section "S0",
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' delineates the quality assurance program requirements.
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Shift Operations states the'following:
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QC for shif t operations is assured by first and second line
I
--
supervisors.
operational monitoring and review of Shif t Operations is provided
,
--
by the Superintendent, Operations; the Operations Engineer; and
I
the PORC/NRB.
QA audits and surveillances are performed by the Quality Assurance
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Division (QAD).
In addition to the above requirements, the licensee's on'-site QC
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group performs monitoring and inspection of shift operations activities.
Thus, the assurance of quality for shif t operations is provided by reviews
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performed by (3) the operations line organization, (2) by the PORC and NRB
'
oversight committees, and (3) by the independent QA0 onsite QA and QC
groups.
The inspector reviewed the Quality Assurance Trending and Tracking System
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These findings
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(QATTS) printout of QA and OC findings since October 1986.
l
QA audits. QA surveillances, QC inspections, and QC monitoring.
include:
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,
- - _ - - _ _ - - _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ - - _ _ _ _ _ _ - _ _ _ _ _ - _ _ _ _ _ _ - _ _ _ _ _
__
. _ . . . . . . . . . .
0
,
,
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,
,
11
The findings are categorized as either nonconformance reports (NCRs),
significant NCRs (SNCRs), recommendations, or QC detailed monitoring
There were no documented negative findings
checklists (DMCs) reports.
with respect to control room operator alertness and attentiveness.
The inspector questioned the onsite QAD QA and QC site supervisors with
respect to control room and licensed operator reviews, particularly during
the weekends and backshift periods. The' inspector could not identify any
case where QA personnel monitored control room activities during the week-
end or backshift periods. QC performs periodic detailed monitoring check-
lists and independent verifications for I&C surveillances. QC was present
in the Control Room for the Unit 3 startup during the period March 10
through 11, 1987. QC personnel provided continuous monitoring, including
backshift observations.
In addition, QC was present in the Control Room
when performing independent verifications signoffs for surveillance test
procedures, which included backshift presence (afternoon-shift 3-11 p.m.)
in the Control Room on the following days (since October 1986):
October 7, 9, 14, 16, 23, 18, 30 (1986)
--
November 6, 13, 18, 20, 25, 27 (1986)
--
December 2, 4, 9, 11, 16, 18, 23 (1986)
--
January 6, 13, 15, 18, 20, 27, 29 (1987)
--
February 3, 5, 10, 12 (1987)
--
March 16, 20, 23, 25 (1987)
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As previously stated no negative findings related to operator alertness
were documented by QC personnel.
No violations were noted.
8.
Event Analysis
8.1 Unit 3 Scram on March 17, 1987
Unit 3 auto scrammed from 86% power at 2:54 a.m. on March 17, 1987,
due to APRM bigh-high flux.
The unit had reduced power on March 16,
1987 from 100% to 86% due to an internal leak in the C2 feedwater
heater. Conditions were normal on the scram. The reactor feed pumps
level decrease.
No ECCS were
(RFPs) recovered the reactor water
initiated.
A group 11 and III primary containment isolation occur-
The recir-
red, due to the reactor level decrease, which was reset.
culation pumps tripped on the 13 KV non-vital bus fast transfer.
.
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Operators restarted both recirculation pumps. The licensee made an
ENS call and notified the Senior Resident Inspector.
!
The licensee determined that the cause of the scram was APRM
high-high flux caused by EHC induced turbine control valve fluctua-
tions. The' unit proceeded to cold shutdown to' repair a leak in the
C2 feedwater heater to perform other maintenance and to investigate
the EHC system malfunction (see section 11.0).
The inspector arrived in the control room at about 6:00 a.m., on
March 17, 1987.
The unit was in hot shutdown at 400 degrees F with
cooldown in progress. The inspector verified that all control rods
were full in as indicated by the process computer 00-7 printout and
the full core display.
The inspector reviewed control room indica-
tors, logs, and discussed the event with the on-shift operators.
Reactor water level dropped to -40 inches as indicated on water level
recorders LR-110A and B.
The RFPs recovered level within 25 seconds.
The inspector noted that several parameters and their control room
strip chart recorders indicated that multiple transients had occurred
The
during the one and a half hours prior to the automatic scram.
"up and down" spiking (fast oscillations) were apparently caused by
the EHC fluctuations. These parameters, instrument numbers and mag-
nitude of oscillations are as follows:
MAGNITUDE OF OSCILLATION
INSTRUMENT NO.
INCHES
% SCALE
NR-46A-F/APRM Flux
1/4" noise and
85
13% reactor power
1/2" oscillations
FR-98/ Steam Flow
0" . noise and
11.8
0.2 x 10' lbm/hr
1/8" oscillations
j
PR and FR-97/ Reactor
1/16" noise and
(1) 11.0 0.4 x 10' lbm/br
Pressure and Turbine
1/4" oscillations
(2) 980
5 psig
Steam Flow
POR-3660/ Turbine
0"
noise and
44
4% open
l
Control Valve-
1/16" oscillations
Position
There were also oscillations on recorder JR-3157 (Generator MWe).
NOTE:
Based on interviews with shift personnel, the inspector concluded
that the operators had not noticed the transients (apparently caused
by EHC induced turbine control valve oscillations) prior to the
j
automatic. scram.
No annunciator nor alarm typer alarms were as-
!
sociated with these recorder indications.
Licensee management also
As a
noted this apparent inattention to control room indications.
._ _
.
.
13
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result,_the licensee issued a memo to all control room operations
personnel on March 19, 1987, reminding them of the need to periodi-
'
cally scan all control room parameters. The specific operators
involved were counselled. The issue of operator inattentiveness to
instrument recorders is unresolved (UNR/277/87-10-03; 278/87-10-03).
The inspector also. reviewed the control room computer alarm typer and
f
sequence of events log, the draf t Upset Report, GP-18 (Scram Review
Procedure), and attended PORC meetings on March 19-20, 1987, to re-
The PORC concluded that the scram was caused by EHC
view the scram.
induced oscillations that resulted in turbine control valves (TCVs)
l
cycling open then closed. On one TCV closing, a pressure spike was
!
sufficient to cause an APRM flux spike high enough to cause a scram
on high-high APRM flux.
Five of the six APRMs initiated scram sig-
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nals. APRM Channel D, which did not trip was later tested satis-
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factorily by the licensee.
At the March 19 and 20, 1987, PORC meetings, Unit 3 restart and an
EHC test program were approved. The test program consisted of EHC
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monitoring during bypass valve operation; bypass and turbine valve
testing at 25% power; and, EHC monitoring during power ascension.
j
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The PORC also approved.special procedure SP-991, " Response to Unit 3
Reactor Parameter Abnormalities", Rev. O.
SP-991 provided operators
with'instructious if EHC problems reoccurred.
As part of the scram reduction program, the ISEG is writing'an Event
Report. The inspector will review the Event Report, the final Upset
Report, and the LER, when they are issued.
8.2 Unit 3 Scram on March 25, 1987
After a four day outage following the scram on March 17, 1987, the
unit was restarted on March 21, 1987.
Prior to the restart, the EHC
system was tested in cold, static conditions and no abnormalities
were observed. To facilitate testing of the EHC system under hot,
dynamic conditions, the reactor was subsequently placed in a hot
standby condition.
The investigation of the EHC system malfunction continued on March 2)
through 25, 1987. A special operating instruction was in place on
to provide the operating staff instructions, should
March 21, 1987,
reactor parameter abnormalities occur similar to those experienced
,
'
prior to the scram on March 17, 1987. The spiking of the turbine
bypass valves reappeared during the hot standby condition on March 21
through 23, 1987.
In order to facilitate the EHC investigation,
certain electronic circuit cards in the EHC system were pulled or
replaced with similar ones from Unit 2 (see section 9 of this
report, for details). With this configuration, the spiking of the
bypass valves stopped at approximately 10:30 p.m. , on March 23, 1987.
1
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However,' turbine bypass valve oscillation (cycling) was observed on
March 24,.1987, when the reactor pressure was increased to'the normal
pressure control setpoint.
.
The unit auto scrammed on low reactor water level at 4:02 a.m., on
. Prior to the scram, the reactor was in a hot standby
March 25, 1987.
condition, with reactor at rated pressure and 1/4 bypass valve open
(power level less'than one percent)'. Troubleshooting was in progress
,
on the EHC system to. determine the reason for the noted bypass valve
j
oscillations observed on March 24, 1987. A test engineer lifted an
{
EHC lead in the electronic circuit (see section 9 of this report,
for details) causing all bypass valves to open. The resulting level
!
swell in the reactor caused a high level trip of the C reactor
feedwater pump (RFP) which was the only RFP then running.
The loss of the RFP and the blowdown due to the open bypass valves
caused the reactor level to drop to about -35 inches. The unit
scrammed on low reactor water level and primary containment group II
and III isolations occurred at 0 inches. The operator restarted the
C RFP and. recovered the reactor level.
No ECCS actuated and condi-
tions were normal on the scram.
The unit was maintained in a shut-
down condition to conduct further EHC troubleshooting.
The inspector will review the LER when it is issued.
No violations
were noted.
8.3 Unit 2 Primary Containment Isolation on March 28, 1987
A group IIB primary containment isolation occurred on Unit 2 while
in cold shutdown at 10:20 a.m.,
on March 28, 1987. The isolation
caused the RHR shutdown cooling suction valves MO-17 and MO-18 to
close.
Shutdown cooling was not in service (RHR pump was secured)
at the time of the isolation.
Fuel movements'were in progress on
i
the' unit. The cause of the isolation was pulling two fuses
associated with the blocking for the scheduled 4160 volt E-12 bus
outage. At 10:40 a.m., the licensee replaced the fuses, reopened
valves MD-17 and 18, and changed the blocking to lifting leads for
the E-12 bus electrical isolation. An ENS call was initiated for
the required four hour notification. The unit was in day 17 of
.
the 71 day scheduled refueling outage, with core offload about 45%
complete.
The inspector reviewed control room logs, the suspected licensee
event report (LER), and the electrical schematic drawings. Fuses
10A-FIA and 10A-F2A were pulled as part of the blocking permit
(tagout) for MRF No. 2-54L8607538.
Pulling these two fuses caused
relay 10A-K114A to de-energize which resulted in a group IIBThis
primary containment isolation on 75 psig reactor pressure.
caused RHR valves MO-17 and 18 to close.
4
.
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.
15
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The inspector attributes the cause of the ev.ent to a blocking
error by the licensed operator. The licensee made the required
four hour ENS call, recovered the shutdown cooling capability
within 20 minutes, and intends to submit an LER for the event.
The
LER and associated corrective actions will be reviewed in a future
,
inspection.
.
-
No violations were noted.
8.4 Unit 3 Primary Containment Isolation on March 31, 1987'
-
]
"
A group IIB primary containment isolation occurred on Unit 3 at
9:25 p.m., on March 31, 1987. The operator was preparing to place
shutdown cooling into service in accordance with procedure
5.3.2.C.1, " Shutdown Cooling Mode - Manual Start and Shutdown",
Rev. 17. While performing the system flush prior to starting
shutdown cooling, suction valves MO-17'and.18 isolated on high
reactor pressure signal (75 psig). The licensee determined that
an in-rush of reactor water and subsequent flashing to steam
caused a pressure spike and the 75 psig isolation to actuate.
Actual reactor pressure was approximately 45 psig. The licensee
reset the isolation and established shutdown cooling by reopening
valves M0-17 and 18.
The inspector monitored control room operations, actions, and
4
reviewed control room logs.
The preliminary licensee event report
(LER), the electrical schematic drawings, and procedure S.3.2.C.1,
" Shutdown Cooling Mode - Manual Start and Shutdown", Rev. 17, were
also reviewed.
Procedure S.3.2.C.1 step #7 requires a flush.of 40
inches (reactor level) through the shutdown cooling lines to the
Valves are required to be operated in the following order:
i
torus.
Close MO-13
--
i
Open MO-38
--
Open MO-37
--
Open MD-15
--
Open MO-39
--
--
Jog open M0-34
The apparent reason for this order is to minimize a possible water
hammer and inrush effect. The inspector noted that the operator
opened MD-15 prior to opening MD-17 and 18.
This apparently
caused the inrush of reactor water and resulted in actuation of
the 75 psig group IIB primary containment isolation.
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Technical l Specification 6.8.1requiresthatwrittenproceduresbe
established, implemented, and maintained per ANSI N18.7-1972
(sections 5.1 and 5.3) and per Appendix "A" of Regulatory Guide 1.33(. November 1972).
Regulatory Guide 1.33, Appendix A', Section
C states that procedures for the Shutdown Cooling System shall be
Sectjon 5.3.4.2 of m l N18.7-1972 requires procedures
prepared.
fo'r shutdown including decay,(,'
removal.
Failure to follow step
Number 7 of procedure S.3.2.C
the correct order is an apparent
violation of TS 6.8.1 (278/87 . ' d4) .
The licensee made the required ENS call, established shutdown
The LER and
cooling, and intends to submit an LER for the event.
associated corrective actions will be reviewed in a future
inspection.
8.5 Loss of Number 3 Startup Offsite Power Source on April 7, 1987
!
At 12:18 a.m., on April 7, 1987, Peach Bottom lost the Number 3
startup (SU) source. This was apparently caused by a loss of a 220
l
KV transmission line in the grid, with subsequent load dispatcher
l
switching,' causing a trip of the 220-34 line (the source of offsite
power for the #3 SU). Thus, a loss of one of the two offsite power
sources occurred. The E-1 diesel. generator (DG) was running at the
time for weekly surveillances and was carrying the E-13 bus in
parallel with the #3 SU (normal power supply). When the #3 SU source
tripped, the E-1 DG picked up the emergency buses that were being
supplied (normally) by #3 SU. These buses included two for Unit 2
Two of the
(E-22 and E-42) and two for Unit 3 (E-13 and E-33).
non-vital 13 KV buses normally supplied by the 3# SU source (#2 and
i
- 3 bus) were also lost. The E-1 DG was loaded to about 3500 KWe
l
Since
(rated for 3100 KWe) and frequency dropped to about 57-58 Hz.
there was no loss of power on the bus no load shedding occurred which
!
caused the diesel overload condition.
(The E-1 DG was subsequently
inspected with no noted problems.) The lower frequency caused the 2B
RPS MG set (Unit 2).and the 3A RpS MG set (Unit 3) to trip. This
resulted 'in a half scram on both units, a half group I isolation on
both units, an outboard isolation group III on Unit 2, and an inboard
.
isolation group III on Unit 3.
,
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a
The half scrams and half group I isolations did not cause any
The group III half (inboard or outboard) isolations' caused-
!
actions.
a loss of normal reactor building ventilation and an isolation of
normal containment ventilation.
The standby gas treatment system
(SGTS) was in service at the time, supplying ventilation for the Unit
Both units were'in the
2 refueling floor and the Unit 3 drywell.
I
cold condition as required by NRC Order.
No fuel movements were in progress on Unit 2 at the time. The
licensee reset the group 111 half isolations, restored power to the
l
non vital Numbers 2 and 3 buses, and aligned the emergency buses per
p'lant procedures (all emergency buses were swapped over to the Number
,
. ..
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,.
.
17
2 SU source, and the E-2 DG was started to supply the E-22 bus).
At
The
6:30 a.m., the Number 3 SU source was returned to service.
licensee then realigned the emergency and non-vital buses to the
normal. shut down lineup.' The licensee determined that this eventAt
should'have been reported due to the group III half isolations.
11:05 a.m., an ENS call was made.-
The inspector discussed this event with control room operators and
. operations engineers. The inspector reviewed control room logs,
,
The
operating procedures, and electrical schematic drawings.
inspector had no further questions at this time. .The LER will be
'.
reviewed. in a future inspection.
Turbine Electro-Hydraulic Control (EHC) System Troubleshooting
9.
As discussed in section 8.2, the licensee, in an attempt to isolate'and
correct the spiking (rapid opening and closing of turbine control
valves) ubserved on the control room recorders (section 8.1), replaced
various printed circuit boards (cards) in the Unit 3 EHC system with
cards from the Unit 2 EHC system. Unit 2 is currently in a refueling
<
The following is a general chronology of actions:
outage.
March 17-20, 1987, shutdown testing of EHC did not identify any
--
problems.
March 21, 1987, plant startup and heatup, dynamic testing started.
--
Spiking of bypass valve noted which caused opening of about one
second duration.
March 22, 1987, various cards pulled and -replaced, (no clear record
--
of which cards) spiking remained.
March 23, 1987, changed Pressure Load Gate (PLG) card, no change in
oscillations noted. Noted bypass valve oscillations of about 5% one-
--
and one-half hours after PLG changed.
Individually removed the "A"
and "B" Steam Line Resonance Compensation (SLRC) cards, spiking
remained.
at approximately 10:30 p.m., the licensee replaced
March 23, 1987,
both the A and B pressure amplifier cards and the A and B SLRC
---
cards with the cards from the Unit 2 EHC system at which time the
spiking stopped.
From the aoove period until approximately 10:00 p.m., on March 24,
1987, the plant was cooled down to reduce pressure to less than
--
600 psig to bypass the low conderser vacuum trip to allow warming of
the low pressure turbine shaft.
4
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18
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March 24, 1987, 10:00 p.m., number one (1) bypass valve was
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observed oscillating between 50 and 75 percent open with the plant-
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at normal operating pressure. Troubleshooting was initiated.
March 25, 1987,.4:02 a.m., reactor scram when lead was lifted
~
--
during troubleshooting. The reactor scram occurred as described
in section 8.2 of.this report. The lead had been lifted in-
.accordance with procedure A-42.1, " Temporary Circuit Modifications
During Troubleshooting of Plant Equipment".
Subsequent to the scram the licensee determined that all bypass valves
opened when lead number T8 702-14 (Electrical Schematic M2-560 Sheet 1 -
I
Revision 5) was lif ted because lifting the lead caused a large increase
in the output of the bypass valve amplifier.
Following the scram the licensee decided to: (1) replace the PLG with the
original card because oscillations observed on March 23, 1987, occurred
after the Unit 2 card was installed. (2) Calibrate the Unit 2 cards (A
!
that were to remain in the
& B pressure amplifiers and the A&B SLRC cards) Unit 2 cards were cali-
Unit 3 EHC. It was originally thought that the
brated to the same attenuation settings as Unit 3 cards.
It was later
determined that Unit 3 SLRC settings were different than Unit 2.
(3)
Replace the EHC cooling fans.
Five out of nine cooling fans had been
identified as out of service on March 23, 1987.
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The inspectors observed that the calibration activities being conducted by
'
the licensee were in accordance with the General Electric Turbine Line Up
Instruction Number.170 x 387 and 170 x 388. The licensee had 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />
coverage being supplied by a corporate PECo EHC engineer and a vendor
representative. During discussions and review of SLRC alignment data, the
>
'
inspector learned that the SLRC card was. basically a notch filter that
attenuated the. magnitude of pressure oscillations of the steam line
)
natural frequency of 0.9 hertz and several harmonics.
The Unit 2 and 3
steam lines have the same natural frequency but the Unit 3 SLRC card re-
quires more attenuation indicating that oscillations are of a larger
)
magnitude than at Unit 2.
Licensee representatives stated that the oscil-
1ations experienced on March 24, 1987, could have been the result of using
the Unit 2 SLRC cards.
No theory about the cause of the original spiking
which caused the trip on March 17, 1987,' had been formulated. All cards
removed from the Unit'3 EHC system will be sent to vendor for dynamic
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testing.
Subsequent to the calibration of the EHC cards tie licensee connected a 13
point . transient' tape recording oevice and a 12 clannel strip chart
recorder. During the plant startup and heatup on March 26 and 27, 1987,
j
the inspectors and the licensee observed the recorder traces which were
steady.
At about 1:00 a.m.. on March 27, 1987, the last new ventilation
)
fan was installed.
During this activity severtl spikes and oscillations
j
were observed on the recorder chart. The para neters that were af fected
were:
.
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4
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' Points 1 and'2, pressure sensor inputs to A and B pressure amplifier
--
circuits..
Points.10 and 11, A and B pressure amplifier. outputs.
--
Point 12, bypass valve position.
--
He also noted
The spiking was discussed with the on-duty test engineer.
that'during previous troubleshooting activities on March 23, 1987, he had
heard noises such as EHC panel ventilation fan blades hitting the fan
Ventilation fans
housings which seemed to correspond to EHC spikes.
observed to be defective were disabled at that time. During the sarna
period the A and B pressure amplifiers and the A and B SLRC cards s
.e
>
replaced. EHC spiking stopped later on March 23, 1987.
The inspector agreed with the licensee test engineer that, although not
conclusive, it appeared that the March 17, 1987, scram could have been-
caused by the electrical noise induced by defective EHC ventilation fans.
24, 1987,
Oscillations in the bypass valve position observed on March
could have been caused by the differences in calibration settings of the
Unit 2 SLRC cards installed in the Unit 3 EHC system.
The inspectors observed the recorder traces to. be very steady after the
fan was electrically connected.
The licensee'is required to submit LERs regarding both the March 17 and
March 25, 1987 scrams.
No violations were identified.
!
10.
LER Analysis
10.1' Scope
The inspector conducted a special review of LERs submitted to the
The
NRC for the period 1985 to present for both Units 2 and 3.
review determined the time of day.for those LERs involving personnel
This includes personnel error induced events, and those
error.
events that were initiated by other root causes (i.e., non-personnel
error) which may have been complicated or made worse by subsequent
For the reportable events occurring on the back
personnel error.
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shifts (primarily 11:00 p.m. to 7:00 a.m.) or on the weekends, the
review determined if the reported personnel error was caused or made
worse by any operator inattent1veness to the controls.
10.2 Conclusion
The inspector reviewed all Peach Bottom LERs from 1985 to present.
Attachment 2 lists all LERs that involve personnel error based on
NRC root cause analysis during previous routine inspections.
For the LERs caused by or made worse by licensed operator errors
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20
during backshif t times, the inspector identi.ff ed one case on a
backshift where operator inattention to duty was potentially
involved (LER 3-85-02) other than the scram on March 17,,1987 -
section 8.3.
The majority of the backshift. errors occurred during
plant startups, shutdowns, or equipment blocking evolutions, which
'
do not appear to have been related to operator inattentiveness.
Further, NRC action regarding personnel errors is unresolved pending
a licensee review of all reportable events for indications of
operator inattentiveness.
(277/87-10-04; 278/87-10-05)
11. Operations Overtime
Station administrative procedure A-40, " Working Hour Restrictions",
Rev. 3, dated October 23, 1985, delineates the working hour
restrictions and overtime policy requirements for all personnel,
including licensed operators. Overtime limits include the following
requirements:
Maximum of 16 hours1.851852e-4 days <br />0.00444 hours <br />2.645503e-5 weeks <br />6.088e-6 months <br /> in a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> period,
--
Maximum of 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> in a 48 hour5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> period,
--
Maximum of 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> in a seven day period, and
--
Minimum of 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> off between work periods.
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Deviations to these requirements inay be authorized by management and
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are documented per form A-46, Exhibit 1.
The control room shif t clerk tracks overtime for licensed operators.
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Shift clerks are assigned to each operating shift to perform administra-
tive duties. The shift clerk tracks hours worked for each operator and
I
maintains a running total for overtime hours to ensure the above require-
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ments are adhered to.
If a deviation is required, the shif t clerk
initiates the A-46, Exhibit I form.
The inspector reviewed procedure A-40 and discussed its implementation
with shift clerks and operations personnel.
The inspector also reviewed
f
overtime / work hour records for the period November 1986 through March
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1987. The inspector noted the following:
l
All on shift licensed reactor operators worked some overtime.
--
i. une
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No operator worked more than 16 consecutive hours without
!
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off.
--
Overtime was consistent with A-40 requirements.
j
Deviations of 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> in a 48 hour5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> period were processed per
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)
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A-40.
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One reactor operator exceeded the 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> in a week twice (deviation
--
processed per.A-40).
Senior reactor operators worked less overtime than reactor
--
operators and no deviations were needed nor' processed.
The inspector reviewed work hours on the day of the Unit 3 scram due to
17, 1987 (see section 11.1). This included all
EHC problems on March
All
control room personnel and related overtime hours for that period.
of the operators worked an eight hour shift (11:00 p.m. - 7:00 a.m.)
that day. Neither the Unit 3 reactor operator nor the senior' operators
on shift worked any overtime for that period. The inspector concluded
that excessive work hours was not a factor in.the March 17, 1987,
apparent inattention to control room indications and resultant
automatic scram.
The inspector asked the licensee for the average overtime hours for 1986
This information was not readily available and it
for licensed operators.
will be reviewed in a future inspection.
No violations were noted.
,
12. Exit Interview Meeting
The inspection ended on April 9,1987. An exit interview was held on
April 9, 1987, to discuss the findings and conclusions by the
inspection team.
13. Appendices
Attachment 1 - Documents Reviewed
Attachment 2 - Personnel Errors, LER Tabulation
Attachment 3 - Surveillances Observed
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ATTACHMENT I
Documents Reviewed
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Nuclear Plant Ru1es, Rev. 2, 1/7/87-
A-7, Shift Operations, Rev. 22, 10/3/86...
IE Information Notice No. 79-20, NRC E;'5
tment Policy - NRC Licensed
Individuals, Rev. 1, 9/7/79
IE Information Notice No. 85-53, Perforn.ir'*.e of NRC-Licensed Individuals
l
While On. Duty, 7/12/85
IE Circular No. 81-02, Performance of NRC-Licensed Individuals While On
Duty, 2/9/81
NRC Regulatory Guide 1.114, Guidance On Being Operator at the Controls of a
'
Nuclear Power Plant, Rev. 1, 11/76
Shift Brief Attendance Sheets (3/24/87-4/3/87)
A-86, Administrative Procedure for Corrective Action, Rev. 5, 1/16/87
Suspected Licensee Event Reports dated 3/28/87 and 3/31/87
QA Plan Volume III
FH-6C " Fuel Movement and Core Alteration Procedure During a Fuel Handling
Outage", Revision 17, October 24, 1984
FH-6C, Appendix 1, " Core Component-Transfer Authorization Sheet"
S-14.1-2, " Operation of the Refueling Platform Controls and Interlocks",
,
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Rev. O, May 8, 1984
A-44, "Special Nuclear Material Accountability"
S-14.2, " Moving Fuel from the Fuel Pool to the Reactor", Revision 5, May 8,
1984
S-14.3, " Moving Fuel from the Reactor'to the Fuel Pool", Revision 7, May 8,
1984
S-14.4, " Moving Fuel Within the Reactor", Revision 7, May 8, 1984
,
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Technical Specifications and Bases, Section 3.10/4.10
-
GEK 9684, Volume VI, " Service'and Handling Equipment"
S-14.5, " Removing Blade Guides from the Reactor and Placing them in the Fuel
l
Pool", Revision 5, May 8, 1984
{
Fuel Pool Drawings, 6280-MIM-5 thru 10
Instruction Manual, " Refueling Platform Equipment Assembly 796E457", Volume
1, PE #6280-MIM-378-1
ST-12.1-2, " Refueling Interlock Functional Test (Unit 2)", Revision 1, June
{
10, 1985
l
- ST-12.1A, "One Rod Permissive Refueling Test", Revision 4, June 21,1984
>
ST-3.1.2, "SRM Core Monitoring Test", Revision 9, January 11, 1985
)
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. . , . .
s
ATTACHMENT 2
Personnel Errors LER Tabulation (1985 thru 1987)
b~ ate / Time
Description
LER
'
Control rod block full out (R0
2-85-26
12/26/85, Noon
error)
,
i
Auto scram during turbine testing
2-85-25
11/29/85, 2:00 p.m.
while shutting down (TE errors)
2-85-24
11/3/85, 1:35 a.m.
Containment isolation blocking error
. R0 error)
(
2-85-21
9/30/85, 9:30 p.m.
Fire pump out of service (R0 error)
2-95-20.
9/24/85, 6:07 p.m.
Scram while shutdown and draining
of reactor to torus (R0 error)..
Torus low level (R0 error)
2-85-17
8/25/85', 7:30 p.m.
2-85-12
8/7/85,.1:39 p.m.
service (R0 error)
l
2-85-02
5/30/85, 4:36 p.:n.
' Scram while shutdown during excess
check valve testing-(TE' error)
1
'l
3-85-26
12/3/85, 4: 35 p.m.
PCIS isolation, when plant operctor
removed wrong fuse
.
3-85-24
11/25/85, 8:40 p.m.
RWCU isolation when plant operator
removed wrong fuse
l
PCIS isolation when wrong fuse
3-85-23
11/15/85, 6:30 p.m.
removed during troubleshooting
3-85-19
11/16/85, 9:45 a.m.
RWCU isolation (I&C technician
,
>
error)
.
Fuel bundle isolated (Refuel error)
3-85-12
8/7/85, 8:30 a.m.
!
Diesel auto start during ST (I&C
'
3-85-10
4/10/85, 12:25 p.m.
]
error)
f
SGTS blocking error (R0 error)
3-85-09
3/28/85. 11:00 a.m.
3-85-08
3/13/85, 9:45 a.m.
Torus High Level (Reactor Operator
l
!
Error)
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];
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2
Reactor mode switch wrong position
j
3-85-02
2/20/85,-4:00 a.m.
during refuel. Potential operator
<
inattentiveness to duty.
~
(R0 blocking error)
'
'2-86-01
3/1/86, 8:27 p.m.
Auto scram on moisture separator
high level (STA Error)
1
2-86-11
3/26/86, 9:00 a.m.
'
Reactor water level transmitter
out-of-service (I&C Error)
{
2-86-18
'8/26/86, 4:00 p.m.
2-86-21
8/13/86, 11:45 p.m.
. Work on core spray valves without
safety blocking (maintenance error)
RWCU isolation while removing leads
3-86-02
2/17/86, 12: 40 p.m.
]
(I&C Tech)
'
PCIS isolation when wrong fuse was
3-86-03
2/19/86, 8:40 a.m.
removed (Plant Operator error)
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3-86-05
3/06/86, 3:30 a.m.
Low level scram during startup
l
involving reactor feedwater pump
speed control.
Low speed stop setting
found too low.
Personnel error
compounded by equipment failure.
(R0 error)
3-86-09
3/18/86, 1-2:30 a.m.
Out-of-sequence control rod during
~;
startup NRC issued $200,000 Civil
Penalty (R0/SRO Errors)
3-86-10
4/11/86, 8:16 p.m.
Reactor low level scram while
using RCIC for level control while
i
shutting down (R0 error)
Auto scram while testing 500 KV line
t
3-86-12
4/26/86, 9:50 a.m.
fault detection circuit (I&C error)
i
Shutdown scram during testing (R0
3-86-13
4/26/86, 7:06 p.m.
error)
Shutdown scram during testing (R0
3-86-14
4/26/86, 7:22 p.m.
error)
3-86-21
10/21/86, 8:00 p.m.
Torus high level (R0 error)
Auto scram during turbine shell
3-86-23
11/4/86, 8:30 p.m.
warming (R0 error)
,
,
.!
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.,
3
3-87-01
3/17/87, 2:54 a.m.
Auto scram due,to EHC oscillations
operators inattentive to their duties.
j
(RO-SRO error)
.\\
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3-87-02
.3/25/87, 4:00 a.m.
Scram during EHC troubleshooting
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(TEerror)
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ATTACHMENT 3
Surveillance and Routine Tests Observed
.
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Routine Test (R1h 5.9, " Exercising of Turbine' Bypass Valves", Rev.1,
performed on Unit 3 on 3/27/87
RT 5.14 " Closure of Control- Valves", Rev.12, performed on Unit 3 on
3/27/87
.
RT 5.0,'" Individual Full Closure of Main Turbine Stop Valves", Rev.12,
i
performed on Unit 3 on 3/27/87
.
Surveillance Test'(ST) 6.6.1, " Daily Core Spray "A" System & Cooler.
Operability", Rev. 10, performed on Unit 3 on 3/27/87
'ST 6.7.1, " Daily Core Spray "B" System'& Cooler Operability", Rev. 12,
performed on. Unit 3 on 3/27/87
ST 6.8.1, " Daily RHR "A" System & Unit Cooler Operability" Rev. 22, .
j
,
performed on Unit 3 on 3/27/87
ST 9.21-3, " Jet Pump Operability", Rev. 9, performed on Unit 3 on 3/28/87-
ST 2.10.15, " Functional Check of the RPS B Card File", Rev. 6, performed on
{
Unit'3
ST 2.10.17, " Functional Check of the RPS 0 Card File", Rev. 6, performed on
Unit 3
l
ST 6.10.1, "HPSW System Operability", Rev. 8, performed on Unit' 3 on 3/28/87
ST 6.6.1,~" Daily Core Spray "A" System & Cooler Operabiitty", Rev. 10,
performed on Unit.3 on 3/27/87
ST 6.7.1, " Daily Core Spray "A" System & Cooler Operability", Rev. 10,
performed on Unit 3 on'3/27/87
ST 3.5.1-3, "RBM Functional & Calibration Test", Rev
4, performed on Unit 3
on 3/28/87-
ST 6.8.1, " Daily RHR "A" System & Unit Cooler Operability",- Rev. 22,
,
.
performed on Unit 3 on 3/28/87
.
ST 8.1.3, " Daily Diesel Generator Full Load Test", Rev. 13, performed
4
3/29/87
ST 6.6.1, " Daily Core Spray "A" System & Cooler Operability, Rev.10,
performed on Unit 3 on 3/29/87
ST 6.7.1, " Daily Core Spray "B" System & Cooler Operability", Rev. 12,
performed on Unit 3 on 3/29/37
i
ST 4.6, " Main Steam Line Monitor Functional & Calibration Test", Rev. 13,
performed on Unit'3 on 3/29/87
ST 6.8.1, " Daily RHR "A". System & Unit Coole'r Operability", Rev. 22,
'
performed on Unit 3 on 3/29/87
ST 6.9.1, " Daily RHR "B" System & Unit Cooler Operability",.Rev. 23,
performed on Unit 3 on 3/29/87
e,T 3.3.1, "APRM Functional & Calibration Test (Scram & Rod Block)", Rev. 20,
performed on Unit 3 on 3/29/87
ST 12.1.8, " Refueling Interlock Functional Test with Inability to Move
)
Control Rods", Rev. 1, performed on Unit 2 on 3/29/87
ST 8.1.3, " Daily Diesel Generator Full Load Test", Rev. 13, performed
3/30/87
ST 9.7, "MSIV Partial Closure & PPS Input Functional Test", Rev. 9,
9
performed on Unit 3 on 3/30/87
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ST 6.6.1, (ST) 6.6.1', " Daily Core l Spray "A" System & ' Cooler '
Operability", Rev. 10, performed on Unit 3 on 3/30/87
)
ST 6.7.1, (ST) 6.6.1, " Daily Core Spray "A" System & Coolei
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Operability",-Rev. 12, performed on Unit 3 on 3/30/87
ST 11.6-2, "Diese'l Generator Simulated Automatic Actuati,on & Load Acceptance
!
Test, "Rev. 8, performed 3/30/87
1
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ST. ,8.1.3, " Daily Diesel Generator Full Load Test", Rev.13, performed
i
on 3/31/87
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ST 6.6.1, " Daily Core Spray "A" System & Cooler Operability", Rev. 10
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r
performed on. Unit 3 on 3/31/87
ST 6.7.1, " Daily Core Spray "A" System & Cooler Operability", Rev. 12,
performed on Unit 3 on 3/31/87
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UNITED STATES
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NUCLEAR REGULATORY COMMISSION .
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sum 2
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WASHINGTON, D. C. 20555 ^
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EDO PRINCIPAL ~ CORRESPONDENCE-. CONTROL-
(
_
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1
JFROM:
DUE: 05/27/87l
EDO CONTROL: '002867-
DOC DT: 05/13/07
SEN.. JOHN.GLENN-
FINAL REPLY:
!
TO:
,
' CHAIRMAN ZECH
>
FOR, SIGNATURE OF
- PRIORITY **
SECY NO: 87-575
' CHAIRMAN
. .DESC: -
ROUTING:
Q'S RES'HUTDOWN.0F PEACH'EOTTOM
STELLO'
TAYLOR'
DATE: 05/18/87.
REHM
ASSIGNED TO: RI
CONTACT: RUSSELL
MURLEY'
MURRAY
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'SPECIAL INSTRUCTIONS'OR REMARKS:
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OFFICE OF THE SECRETARY
CORRESPONDENCE CONTROL TICKET
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PAPER NUMBER:
CRC-87-0575
LOGGING DATE: May 1B 87
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-ACTION OFFICE:
300
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AUTHOR:
J. Glenn
AFFILIATION:
U.S.-SENATE
LETTER DATE:
May 13 87
FILE CODE: ID&R-5 Peach Bottom
SUBJECT:
Would like to know Comm's reasons for shuting down
the Peach Bottom power plant, including dates &
steps involved, along with any allegations of
problems
ACTION:
Signature of Chairman
DISTRIBUTION:
RF, OCA to Ack
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SPECIAL HANDLING: None
NOTES:
DATE DUE:
May 30 87
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SIGNATURE:
DATE SIGNED:
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AFFILIATION.
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IDO --- 002867
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